THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT 
Emil  Bogen,  M.D. 


TUBERCULIN    AND 
VACCINE 

IN 

TUBERCULAR    AFFECTIONS 


A  Practical  Guide  for  the  Utilization 

of  the  Immune  Response  in 

General  Practice 


BY 


ELLIS  (BONIME,  M.  D. 

Adjunct  Professor  of  Surgery  and  Division  of  Immunotherapy, 
New  York  Polyclinic  "Medical  School  and  Hospital 


THE  SOUTHWORTH  COMPANY,  PUBLISHERS 

TROY,  NEW  YORK 

1917 


COPYRIGHT,  1917 
BY  THE  SOUTHWORTH  COMPANY 


WF 


To  the  memory  of  my 

MOTHER, 
whose  sacrifices  have  shaped  my  career, 

and  to 

Prof.  JOHN  ALLEN  WYETH,  M.D.,  LL.D., 
who  has  given  me  the  opportunities  that  made  my 

experiences  possible, 
this  work  is  gratefully  dedicated  by  the  Author. 


FOREWORD 
By  JOHN  ALLEN  WYETH,  M.  D.,  LL.  D. 

Having  demonstrated  to  my  complete  satisfaction  that 
the  persistent  and  carefully  adjusted  injection  of  tuberculin 
will  cause  to  disappear  lymphatic  glands  enlarged  with  the 
inflammatory  products  of  bacilli  of  tuberculosis,  I  undertook 
to  establish  a  clinic  in  connection  with  my  department  of 
general  surgery  at  the  New  York  Polyclinic  Medical  School 
and  Hospital,  at  which  these  cases  could  be  treated.  Dr. 
Ellis  Bonime  was  placed  in  full  charge  of  this  clinic.  His 
careful  technique  and  conscientious  study  of  each  of  these 
numerous  subjects  who  presented  themselves  for  treatment 
gave  a  final  confirmation  to  the  results  of  our  preliminary 
work.  As  will  be  shown  in  the  text  of  this  volume,  the 
beneficial  effects  of  Koch's  tuberculin  are  now  also  demon- 
strated in  bone  and  skin  tuberculosis,  and  the  earliest  stages 
of  pulmonic  involvement. 

To  this  department  has  been  added  the  treatment  of 
various  infections  by  the  use  of  vaccines  and  sera,  a  branch 
of  surgical  therapeutics  as  yet  not  as  insistently  taught  or 
as  widely  practiced  as  our  experience  would  seem  to  justify. 

JOHN  A.  WYETH. 


PKEFACE. 

There  is,  perhaps,  no  therapeutic  agent  which  has  so 
checkered  a  history  as  tuberculin.  Every  medical  man  is 
acquainted  with  the  story  of  its  rise  and  of  its  sudden  fall ; 
of  the  prejudices  and  vicissitudes  that  have  beset  its  career. 
However,  we  believe  that  the  days  for  defending  and  apolo- 
gizing are  past,  and  that  every  physician  who  has  given 
the  subject  any  serious  thought  is  convinced  that  in  tuber- 
culin we  have  the  medium  through  which  tuberculosis  is 
destined  to  be  conquered.  However,  to  get  any  adequate 
control  of  this  plague,  we  require  a  method  for  the  use  of 
tuberculin  which  will  enable  the  general  practitioner  to 
handle  it  safely.  Once  the  general  practitioner  is  able  to 
cope  successfully  with  tuberculosis  by  means  of  tuberculin, 
the  public  will  gain  faith  in  tuberculin.  We  have  come  to 
realize  that  the  education  of  the  public  is  quite  as  important 
as  proper  treatment.  The  idea  that  the  climatic  treatment 
of  tuberculosis  is  the  only  one  known,  and  thus  means  ban- 
ishment from  home  and  occupation,  has  occasioned  a  dread 
of  the  disease  which  has  created  a  fear  of  diagnosis  rather 
than  a  rush  for  early  treatment.  There  is  no  better  way  of 
educating  the  public  to  come  for  early  treatment  than  to 
have  a  method  of  treatment  in  the  hands  of  the  general  prac- 
titioner which  will  make  him  able  and  willing  to  take  the 
responsibility  for  treatment  instead  of  shifting  it  by  sending 
his  patients  away. 

The  need  of  such  a  method  struck  me  in  the  course  of 
my  work  in  surgery.  I  soon  noticed,  as  most  surgeons  do, 
the  futility  of  surgery  in  tubercular  conditions.  As  I  had 
a  large  and  successful  experience  in  the  use  of  the  immune 
response  in  vaccine  therapy  in  all  forms  of  surgical  infec- 
tions, I  could  not  help  thinking  that  there  must  be  some  way 
of  utilizing  the  immune  response  in  tubercular  conditions, 
especially  where  surgery  so  often  proves  hopeless,  and  where 


VI 11 


PfiEFACE 


other  forms  of  treatment  would  be  so  welcome.  Thus  it 
was,  that  when  Dr.  John  D.  Murphy  of  Chicago  made  his 
announcement  that  over  a  period  of  two  years  he  had  been 
able  to  avoid  operations  on  cervical  adenitis  by  the  use  of 
tuberculin,  I  began  to  use  tuberculin  in  this  condition,  with 
pronounced  success.  As  my  experience  with  the  use  of 
tuberculin  grew,  I  became  more  and  more  convinced  as  to 
the  §fficacy  of  the  artificially  induced  immune  response  in 
tubercular  conditions.  As  I  went  further  into  the  literature 
on  the  subject,  and  observed  the  physiological  action  of 
tuberculin,  I  came  to  realize  that  the  immuno-mechanism 
in  tuberculosis  was  exactly  the  same  as  in  any  other  infec- 
tion, except  that  the  hypersusceptibility  and  the  production 
of  substances  during  the  immune  response  was  responsible 
for  the  dangerous  element  in  the  improper  use  of  tuberculin. 
I  observed  that  the  hesitation  on  the  part  of  the  profession 
to  use  tuberculin  was  due  to  the  necessity  of  judging  the 
patient's  degree  of  hypersusceptibility. 

Working  along  these  lines,  I  finally  evolved  a  system  of 
dosage  which  eliminates  the  necessity  for  judging  the  hyper- 
susceptibility of  the  individual,  and  controls,  to  a  very  great 
extent,  the  degree  of  constitutional  reaction.  My  method 
has  been  tried  out  for  five  years  at  the  New  ,York  Polyclinic 
Hospital,  at  the  Newark  Home  for  Crippled  Children,  in 
an  extensive  private  practice,  and  in  several  years'  experi- 
ence of  a  number  of  my  colleagues,  who  have  been  kind 
enough  to  keep  me  constantly  in  touch  with  their  work.  It 
is  at  the  request  of  these,  and  of  the  physicians  who  come 
to  the  Polyclinic  Hospital  for  short  courses  in  medicine,  that 
I  have  set  down  the  results  of  my  experiences  in  written 
form. 

This  volume  will  be  as  short  and  simple  as  possible,  and 
will  avoid  all  complicated  theories  and  technicalities.  Its 
aim  is  two-fold :  It  seeks  first  to  unfold  a  method  that  will 
attract  the  general  practitioner.  I  hope,  in  this  way,  to 
help  in  extending  the  field  of  tuberculin  therapy  far  beyond 
the  narrow  scope  of  the  specialists, — as  there  cannot  possibly 


PREFACE  ix 

be  enough  specialists  to  reach  the  majority  of  sufferers  from 
tuberculosis.  My  other  aim  is  to  reach  those  patients  who 
have  to  continue  their  daily  work  while  under  treatment. 
We  know  that  these  are  by  far  the  vast  majority  and  that 
they  are  the  greatest  menace  in  the  spread  of  the  disease. 
In  short,  I  aim  at  an  ambulatory  treatment  simple  enough 
to  reach  physicians  in  every  nook  and  corner,  even  where 
the  best  facilities  are  not  at  hand. 

I  wish  to  express  my  appreciation  of  the  works  of  those 
authors  who  have  written  so  fully  and  convincingly  on  tuber- 
culosis and  tuberculin  for  what  they  have  done  to  make  my 
experience  possible.  As  my  book  is  merely  a  practical  guide 
to  the  use  of  the  immune  response  in  tuberculosis  I  could 
not  at  every  point  tell  whether  my  idea  arises  from  my  own 
experience  or  from  the  reading  of  the  literature  on  this  sub- 
ject, and  I  did  not  interrupt  my  work  to  make  the  distinc- 
tion. So  that  if  I  failed  to  make  frequent  mention  of  those 
authorities  in  my  work,  it  is  not  from  lack  of  appreciation 
or  from  a  desire  to  appear  altogether  original. 

To  Doctor  Charles  Gottlieb  for  the  excellent  radiographs ; 
to  Doctor  .Sidney  T winch  for  the  material  at  the  Newark 
Home  for  Crippled  Children;  and  to  my  associates  at  the 
Xew  York  Polyclinic  Medical  School  and  Hospital  for  their 
assistance,  I  am  greatly  indebted. 

ELLIS  BONIME. 
York,  August,  1917. 


CONTEXTS 

PAGE 

FOREWORD— By  John  Allen  Wyeth,  M.D.,  LL.D v 

PREFACE — vii 

PART  I 
Tuberculin  in  Diagnosis 

CHAPTER  I 

INTRODUCTION -. . . .         1 

Immunity — Mechanism  of  Immunity — Opsonins — Antibodies 

CHAPTER  II 

THE  NATURE  OP  TUBERCULINS 7 

Type  1,  or  Tubercular  Filtrates — Type  2,  or  Bacillary  Bodies — 
Type  3,  or  Type  1  and  2  Combined 

CHAPTER  III 

CHOICE  OF  TUBERCULIN 12 

Dilutions — Directions  for  Making  Dilutions — Stability  of  Dilu- 
tions 

CHAPTER  IV 

THE  TUBERCULIN  REACTION  IN  DIAGNOSIS 17 

Indication  for  Tests — Interpretation  of  the  Tests — Dosage — 
Contraindications — Determination  of  the  Tuberculin  Test — 
Cutaneous  Tests — Escherich's  Needle  Tract  Reaction — Percu- 
taneous Test  of  Moro — Intra-cutaneous  Test — Conjunctival 
Test — Subcutaneous  Tuberculin  Test — Symptoms  of  the  Tuber- 
culin Constitutional  Reaction 

PART  II 
Tuberculin  in  Treatment 

CHAPTER  I  PAGE 

EQUIPMENT 42 

Proper  Record  Sheets  or  Cards — Syringe — Needles — Office 
Scales — Containers  for  Dilutions — Instructions  to  Patients 

CHAPTER  II 

TUBERCULIN  TREATMENT 51 

Principles  Underlying  the  Action  of  Tuberculin — Scheme  of 
Dosage — Dosage  Tables — Intervals — The  Relation  of  Dosage 
to  Individual  Tolerance  or  Hypersusceptibility — Advisability  of 
Acquiring  the  Tuberculin  Technique  by  First  Treating  Cases 
Where  Severe  Reactions  Will  Not  Be  Dangerous 


xii  CONTENTS 

CHAPTER  III  PAGE 

TUBERCULOSIS  OF  THE  GLANDS 68 

Classification — Closed  Glands — Open  Glands — Recurrent  Glands 
After  Radical  Operation — General  Hypersusceptibility — Begin- 
ning Treatment — Conclusion  of  Treatment — Results 

CHAPTER  IV 

BONE  AND  JOINT  TUBERCULOSIS 85 

The  General  Consideration  of  the  Complexity  of  Processes  In- 
volved— General  Hypersusceptibility — Beginning  Treatment — 
Conclusion  of  Treatment — Results 

CHAPTER  V 

RENAL  TUBERCULOSIS 95 

A  General  Consideration  of  the  Present  Status  of  This  Form  of 
the  Disease — General  Hypersusceptibility — Beginning  Treat- 
ment— Conclusion  of  Treatment 

CHAPTER  VI 

PULMONARY  TUBERCULOSIS 105 

General  Consideration — Contra-indications  To  the  Use  of 
Tuberculin — Classification — Incipient — Chronic  or  Slowly  Pro- 
gressive— Acute  or  Active — General  Hypersusceptibility — Treat- 
ment— Prognosis  and  Results 

CHAPTER  VII 

MISCELLANEOUS  TUBERCULAR  CONDITIONS 132 

Tuberculosis  of  the  Pleura — Tubercular  Peritonitis — Tubercu- 
losis of  the  Eye — Tuberculosis  of  the  Ear — Tuberculosis  of  the 
Skin 

CHAPTER  VIII 

SPECIAL  CONDITIONS 142 

The  Constitutional  Reaction  in  Treatment — Tuberculin  Intol- 
erance —  Abscess  Formation  —  Auto-inoculation  —  Tri-monthly 
Tests 

PART   III 
Special  Treatment 

CHAPTER  I  PAGE 

INTRODUCTION— "THE  COMBINED  THERAPY" 153 

CHAPTER  II 

MIXED  INFECTION 157 

Diagnosis  of  Infective  Organism — Smear — Cultures — Animal 
Inoculation — Diagnosis  by  Physical  Signs 


CONTENTS  xiii 

CHAPTER  III  PAGE 

VACCINES 164 

Preparation — Standardization — Containers — Care  of  Vaccines — 
Stock  Vaccines — Autogenous  Vaccines 

CHAPTER  IV 

TREATMENT  OF  MIXED  INFECTIONS 173 

Acute  Mixed  Infections — Febrile  and  Afebrile — Chronic  Mixed 
Infections 

CHAPTER  V 

MIXED  INFECTIONS  IN  PULMONARY  TUBERCULOSIS 184 

Chronic  Respiratory  Mixed  Infections — Mixed  Infections  Which 
Follow  Upon  a  Tubercular  Process — Mixed  Infections  Which 
Act  as  Fertilizer  for  the  Tubercular  Process — Acute  Respiratory 
Mixed  Infections  —  Treatment  —  Prophylactic  Immunization 
Against  Mixed  Infections — Prophylactic  Immunization  Against 
Epidemic  Infections — Prophylactic  Immunization  Against  Acute 
Exacerbations — General  Prophylaxis — Elimination  of  Sources 
of  Infection — Personal  Hygiene — Dietetics 

CHAPTER  Vl 
SURGICAL  MEASURES 205 

CHAPTER  VII 

THE  SURGICAL  TREATMENT  OF  TUBERCULAR  GLANDS 208 

Soft  Glands — Suppurating  Glands — Cicatrized  Glands 

CHAPTER  VIII 

BONE  CAVITIES,  SINUSES  AND  FISTULAS 213 

Mixed  Infection — Treatment 

CHAPTER  IX 

BISMUTH  PASTE 217 

Composition  of  Bismuth  Paste — Bismuth  Paste  Injections — 
Bismuth  Paste  Retention — Frequency  of  Treatment — The 
Proper  Direction  of  Bismuth  Paste — Roentgenography 

CHAPTER  X 

COLD  ABSCESSES 226 

Treatment 

CHAPTER  XI 

EMPYEMA  AND  LUNG  ABSCESS 231 

Treatment — Vaccines  Against  Infections — Modified  Surgical 
Measures  for  Drainage  or  for  the  Removal  of  Purulent  Materi- 
als— Local  Treatment  for  .the  Prevention  of  Reaccumulations 
of  Purulent  Materials  and  for  the  Stimulation  of  the  Healing 
Process 


LIST  OF  ILLUSTRATIONS 

FIGURE  PAGE 

1  Tuberculin  All-glass  Syringe 14 

2  Tuberculin  Record  Syringe 14 

3  Bottles  for  Dilutions  for  Office  Use (facing)       16 

4  Bottles  for  Dilutions  for  Hospital  Use (facing) 

5  The  Positive  Von  Pirquet  Reaction (facing) 

6  The  Subcutaneous  Tuberculin  Test  (Injection) (facing) 

7  The  Subcutaneous  Tuberculin  Test  (Treatment  of  Puncture) 

% (facing)      40 

8  The  Subcutaneous  Tuberculin  Test  (Local  Reaction) .  (facing)       40 

9  Record  Sheet  (for  History) 45 

10  Record  Sheet  (for  Tuberculin  Record) 45 

11  Chart    I — (Relation  of  Tuberculin  to  Patient's  Tolerance) . .  . 

(facing)      62 

12  Chart  II — (Comparative  Results  of  Methods  of  Tuberculin 

Administration) (facing)       63 

13  Illustrates  the  Three  Stages  in  One  Individual :   Glands ;  Bone ; 

Lungs (facing)       68 

14  Illustrates  the  Three  Stages  in  a  Child:    Glands;  Bones;  Pul- 

monary  (facing)      68 

15  Illustrates  the  First  and  Second  Stage:    Glands  of  the  Neck 

and  Bone (facing)       70 

16  An  Example  of  Hard  Cicatrized  Glands  After  Connective  Tis- 

sue Change (facing)       80 

17  Shows  the  Difference  Between  a   Radical  Operation  Before 

Tuberculin  Treatment  and  a  Cosmetic  Operation  After 
Tuberculin  Treatment (facing)       80 

18  Open  Tubercular  Glands (facing)       80 

19  Open  Tubercular  Glands (facing)       80 

20  Illustrates  a  Radical  Operation  With  Extensive  Recurrence  a 

Few  Months  After  the  Operation (facing)       80 

21  Illustrates  a  Radical  Operation  With  Immediate  Recurrence, 

With  the  Extension  of  the  Process  to  the  Apex  of  the  Lung  80 

22  Post-operative  Recurrent  Glands (facing)  80 

23  Post-operative  Recurrent  Glands (facing)  80 

24  Post-operative  Recurrent  Glands (facing)  84 

25  The  Effect  of  the  Removal  of  a  Local  Lesion  in  a  Constitu- 

tional Disease (facing)       88 

26  The  Effect  of  the  Removal  of  a  Local  Lesion  in  a  Constitu- 

tional Disease (facing)  94 

27  Hip  and  Ankle  Tuberculosis (facing)  96 

28  X-ray  Photograph  of  the  Patient  Shown  in  Fig.  27. ..  (facing)  96 

29  Shows  the  Same  Patient  as  in  Figs.  27  and  28,  and  Shows  a 

Complete  Cure (facing)      96 


ILLUSTRATIONS  xv 

FIGURE  PAGE 

30  Hip  and  Ankle  Tuberculosis (facing)  96 

31  X-ray  of  the  Same  Patient  as  Fig.  30 (facing)  96 

32  Hip  Disease  and  Tubercular  Peritonitis (facing)  96 

33  X-ray  of  the  Same  Patient  as  Fig.  32,  Which  Shows  the  Ex- 

tent of  the  Tubercular  Process  in  the  Hip (facing)       96 

34  Shows  the  Healed  Condition  of  the  Same  Patient  as  Fig.  32. . 

(facing)       96 

35  X-ray  of  Chest  (Pulmonary  Tuberculosis) (facing)     124 

36  X-ray  of  Chest  (Same  Patient  as  Fig.  35,  Ten  Months  Later) 

(facing)  128 

37  X-ray  of  Chest  (Acute  Febrile  Pulmonary  Tuberculosis)  (facing)  130 

38  X-ray  of  Hour-glass  Stomach  (Tubercular  Peritonitis)  (facing)  136 

39  Temperature  Chart  (Determination  of  Constitutional  Reac- 

tion)      143 

40  Temperature  Chart  (Effect  of  Contagious  Disease  of  Hyper- 

susceptibility)  151 

41  Temperature  Chart  (Effect  of  Contagious  Disease  on  Hyper- 

susceptibility)  152 

42  Pyogenic  Bacteria,  Methylene  Blue  Stain (facing)  160 

43  Containers  for  Vaccine (facing)  166 

44  Taking  of  Vaccine  from  Container (facing)  166 

45  Temperature  Chart  (Relation  of  Vaccine  Administration  to 

Temperature  Curve) (facing)     176 

46  X-ray  of  Chest  (Circumscribed  Mixed  Infection) (facing)     202 

47  X-ray  of  Chest  (Slowly  Progressive  Tubercular  Lesions,  the 

Mixed  Infection  Preventing  Complete  Healing) . .  (facing)     202 

48  X-ray  of  Chest  (Tubercular  Process  Superimposed  on  Chronic 

Mixed  Infection) (facing)  204 

49  Cut  of  Knife 209 

50  Proper  Direction  of  Bismuth  Paste  (Schematic  Drawing)  (facing)  224 

51  Proper  Direction  of  Bismuth  Paste  (X-ray  at  Beginning  of 

Treatment) (facing)     224 

52  Proper  Direction  of  Bismuth  Paste  (Fig.  51  at  Conclusion  of 

Treatment) (facing)     224 

53  Proper  Direction  of  Bismuth  Paste  (X-ray  of  Tubercular  Hip) 

(facing)     224 

54  Proper  Direction  of  Bismuth  Paste  (Photograph  of  Fig.  53) . . 

(facing)     224 

55  Proper  Direction  of  Bismuth  Paste  (Tubercular  Coxitis) 

(facing)     224 

56  A  Pulmonary  Abscess  Draining  Into  the  Pleura  and  Produc- 

ing an  Empyema (facing)     234 

57  A  Pulmonary  Abscess  Draining  Into  a  Bronchus (facing)     236 

58  A  Pulmonary  Abscess  Draining  Into  a  Bronchus  and  Into  the 

Pleura (facing)     236 

59  An  Extra-pleural  Abscess  Previously  Diagnosed  and  Treated 

as  Empyema  Complicating  Pulmonary  Tuberculosis 

(facing)     238 


PART  I 

CHAPTER  I 

INTKODUCTION 

Excepting  instances  of  the  immunity,  which  is  natural 
or  hereditary,  and  the  passive  immunity,  where  the  infec-  immunity  is 

.  i  -i       always  the 

tion  was  in  some  other  animal,  all  immunity  is  the  result  resuit  of 
of  infection  which  stimulated  the  body  cells  to  the  formation  in£ectlon- 
of  specific  antibodies.     The  infection  may. either  be  caused 
by  living  bacteria,   virulent  or  avirulent,   or  to   a   milder 
degree  by  dead  bacteria. 

The  word  "  immunity,"  as  generally  understood,  means 
a  state  of  the  organism  as  resisting  a  special  invasion,  but  immunity 
we   must   include   the   mechanism   by   which   this    state   is  f™  ["ms  ^ 
acquired  in  its  broader  meaning.     When  such  an  invasion  process  going 
occurs,  either  by  the  micro-organism  or  by  a  physical  or  establishment 
chemical  cause,   the  normal  physiological  processes  of  the  of  the  state  of 

*     "  resistance  to 

body  are  interfered  with  and  physical  and  chemical  changes  the  particular 
immediately  take  place  in  the  organism  to  counteract  it; 
and  when  this  counteraction  is  accomplished,  changes  again 
take  place  which  gradually  reinstate  the  normal  processes. 

The  defensive  processes,  plus  the  natural  tendency  to 
return  to  normal,  are  included  in  the  mechanism  of  immu- 
nity, so  that,  whether  toxic  substances  or  bacterial  substances 
have  formed  the  abnormal  state,  the  gradual  return  to  normal 
is  the  immunity  acquired,  whether  it  be  a  toxic  immunity 
or  a  bacterial  immunity. 

In   the   case   of   infections,   we  may  have   a   bacterial  The  immunity 

.  ,       ,         .  ,  ,  .  .  .  .  ,        may   be  against 

immunity  to  deal  with — that  is,  an  immunity  against  the  the  organisms 

direct   action   of   the  bacteria ;    or,   we  may  have  a   toxic    or  its  toxins  or 

.  .  .  both- 

immunity  to  deal  with — that  is,  the  acquirement  of  immu- 
nity against  toxic  substances  which  the  bacteria  liberate, 
either  through  their  metabolism  or  through  their  death;  or, 
we  may  have  a  combination  of  the  two — that  is,  we  may 
have  an  invading  organism  which  not  only  does  harm  by  its 
1 


TUBERCULIN  AND  VACCINE 


Where  the  two 
exist  treatment 
is  complicated. 


Active 
immunity 


and 


passive 
immunity. 


A   combination 
of  the  two 
advisable  in 
suitable  cases. 


The  protective 
mechanism  of 
the  host 
consists  of 
two  elements; 

the 
Phagocytes 


and 


multiplication  and  extension  in  the  tissues,  but  may  also 
produce  toxic  substances  which  in  themselves  form  protein 
poisons,  doing  damage  to  the  organism. 

It  is  in  this  latter  form  that  treatment  seems  most  diffi- 
cult, as  the  established  use  of  vaccines,  while  active  against 
the  organism,  fails  to  produce  any  results  against  the  toxicity. 
On  the  other  hand,  the  use  of  antitoxins,  while  neutralizing 
this  toxic  substance,  still  allows  the  bacteria  to  multiply  and 
produce  more  toxicity  and  direct  damage  by  their  presence. 

There  are  two  ways  in  which  the  organism  can  acquire 
immunity.  One -way  is  by  the  natural  physiological  process 
in  the  organism,  whether  set  in  motion  by  the  organism 
directly,  or  whether  stimulated  by  outside  agencies.  This 
is  called  active  immunity.  However,  the  discovery  was  made 
that  the  sera  of  immunized  animals  retained  the  immune 
substances  which  we  are  able  to  transfer  to  the  sera  of  other 
animals,  thus  merely  placing  immunity  into  the  circulation 
without  the  necessity  on  the  part  of  the  recipient  to  form  his 
own  immune  substances.  This  was  called  passive  immunity. 

It  might  be  well  at  this  point  to  bring  out  the  fact  that 
one  form  of  immunity  does  not  preclude  the  other  in  the 
same  organism  against  the  same  infection.  We  can  stimu- 
late the  mechanism  of  the  immunity  in  a  given  individual 
by  certain  substances  and  find  this  stimulation  either  too 
slow  or  insufficient  and  so  use  a  passive  immunizer  at  the 
same  time. 

• 

The  Mechanism  of  Immunity 

Since  the  protective  mechanism  of  the  host  is  specific 
against  each  organism,  we  can  easily  see  how  extremely 
complicated  and  for  the  most  part  theoretical  our  present 
knowledge  of  the  subject  still  remains. 

However,  the  two  most  important  methods  of  protection 
stand  out  very  prominently.  The  first  and  most  far-reaching 
is  the  mechanism  of  phagocytosis  with  the  production  of 
substances  which  render  the  invader  amenable  to  phagocytic 
action. 


INTRODUCTION  3 

The  second  protective  process  deals  with  the  formation  Antibodies 
of  substances  in  the  blood  stream  and  in  the  body  sera  that 
act  directly  on  the  invader  in  various  ways,  to  destroy  or 
neutralize  the  poisons  of  the  invader. 

Taking;  up  the  subject  of  phagocvtosis  in  detail,  we  find   The  Phas°- 

r       °      "  cytesandthe 

that  in  order  that  it  prove  effective  at  all,  substances  must   opsonins  which 
form  which  combine  with  the  invader  to  render  it  absolutely  ™cation  possible 
susceptible  to  phagocytic  action.     These  substances  we  call 
opsonins. 

These  opsonins  are  negative  to  each  invader  and  the 
amount  of  protection  they  give  the  host  is  in  direct  propor- 
tion to  its  quantitative  existence  at  the  time  of  invasion. 
This  fact  has  brought  out  the  subject  of  opsonic  index. 
Wright  has  found  that  the  amount  of  opsonins  present  in  Determination 

,.,..,,  .  .  .  ,  of  amount  of 

each  individual  at  the  time  of  invasion  can  be  determined ;  protection, 
thus,  a  measure  for  the  amount  of  protection  on  the  part  of 
the  host  is  at  hand.  By  this  measure  we  are  able  to  deter- 
mine at  any  given  moment  during  an  invasion,  whether  the 
host  or  the  invader  has  the  better  of  the  combat;  and  it  has 
been  undertaken  to  constantly  measure  this  protection  in 
order  to  determine  the  period  for  rendering  outside  assis- 
tance to  the  host. 

Further  work  in  vaccine  therapy  has  shown  that  clinical 
symptoms  are  sufficient  to  indicate  both  the  necessity  and  the 
intervals  for  outside  interference,  making  this  tedious  and 
highly  specialized  process  of  opsonic  index  determination    ppsonic 
unnecessary.     This  is  rather  fortunate;  for,  if  the  treatment    unnecessary, 
with  vaccines  depended  on  the  determination  of  the  opsonic 
index,  vaccine  therapy  would  have  died  out  completely,  or 
smouldered  in  the  hands  of  the  few. 

Opsonins.  There  are  two  conditions  absolutely  neces- 
sary for  opsonins  to  play  an  effective  part  in  the  course  of 
the  infection.  First,  the  bacterial  invader  must  be  suscep-  Conditions  for 
tible  to  opsonic  action,  and  secondly  leucocytes,  capable  of 
active  phagocytic  action  upon  the  opsonized  bacteria,  must 
be  present. 

The  number  of  staphylococci  taken  up  by  100  leucocytes 


opsonic 

veness. 


4  TUBERCULIN  AND  VACCINE 

in  a  mixture  of  leucocytes,  staphylococci  and  serum  of  the 
patients   suffering  from  furunculosis  may  be  200.      In   a 
smaller  mixture  of  normal  serum,  under  the  same  conditions, 
100  leucocytes  may  contain  400  staphylococci. 
Method  of  Wright    found    from    repeated    determinations    of    the 

opsonic  index  .  .. 

determination      opsonic  index  that  a  curve  niay  be  plotted  which  has  the 
which  proved       nreneral  characteristics  of  other  antibodies.     The  curve  may 

that  small 

doses  of  vaccine  be  modified  by  the  inoculation  of  small  amounts  of  culture 
of  the  organism  causing  the  infection.  The  course  of  the 
curve  depends  on  the  amount  and  toxicity  of  the  dose ;  thus 
small  doses  tend  to  raise  the  curve.  A  larger  inoculation 
causes  first  a  depression  of  the  curve  below  normal  (negative 
phase)  and  then  increases  it  to  a  point  considerably  higher 
than  before  (positive  phase).  If  the  amount  of  inoculation 
is  still  larger,  the  negative  phase  is  more  marked  and  of 
abnormal  duration;  and  may  or  may  not  be  followed  by  a 
positive  phase  depending  upon  the  amount  of  excess  dosage. 
The  aim  of  small  doses  of  vaccine,  such  as  would  give  the 
maximum  dose  of  opsonic  response  and  the  necessity  of 
giving  doses  at  sufficient  intervals  of  time  to  allow  of  the 
development  of  the  maximum  reaction  from  previous  inocu- 
lation, were  repeatedly  emphasized  by  Wright. 

Antibodies.  In  dealing  with  the  second  form  of  pro- 
tection, in  which  the  substances  act  directly  on  the  invading 
organism,  we  have  three  distinct  forms : 

in  the  immune  In  the  first  place,  we  have  substances  which  tend  to 

response  there  ,  .  ..  /•     i        •  i  •  •  mi 

is  a  production     paralyze  the  activity  of  the  invading  organism.     Ihese  sub- 
Of  substances       stances  are  known  as  precipitins  and  agglutinins. 

acting  directly 

on  the  invader.  Second,  we  have  substances  combining  chemically  with 

the  bacteria,  causing  them  to  disintegrate.  This  class  of 
antibodies  is  known  as  lysins. 

Third,  we  have  substances  neutralizing  the  toxins  set 
free  by  the  bacteria,  the  substances  being  designated  as 
antitoxins. 

Vaughn  and  others  have  shown  that  if  bacteria  are 
digested  by  chemical  means  or  by  treatment  with  the  bac- 
teriological serum,  that  the  toxicity  of  the  suspension  is 


INTRODUCTION  5 

enormously  increased.  The  inoculation  of  such  a  suspension 
in  animals  was  observed  to  produce  highly  toxic  symptoms. 
Thus,  the  host  may  produce  a  digestive  substance  as 
a  part  of  the  defensive  mechanism,  —  that  is,  for  the  diges- 
tion of  the  bacteria  which  might  produce  a  very  highly 
toxic  combination  and  which,  in  its  absorption,  may  seriously 
injure  the  host;  or,  it  may  cause  a  local  proteolysis  of  the 
host's  own  tissues.  Or,  the  defensive  substances  (anti- 
bodies) produced  by  the  immune  response,  in  combining 
chemically  with  the  invading  organisms  (bacteria)  may  The  end- 
form  proteins  which  are  highly  toxic  to  the  host.  un'i 


Proteins  .derived  from  the   action  of  antibodies  upon  body  with  the 

i  •  •,  i'ii  •  -pit  invader  may 

bacteria  may  become  highly  toxic  to  the  host  11  the  host  be  toxic  to 
possesses  a  hypersusceptibility  (idiosyncrasy)  to  these  pro-  ^oTfiT"1"*1 
terns.     "  Anaphylaxis  "  is  the  term  applied  to  the  syndrome  sensitive  to 
complex  produced  by  the  action  of  these  proteins  in  hyper- 
sensitive individuals;  while  /"  allergy  "  is  the  term  applied 
to  the  state  of  hypersusceptibility  produced  in  an  animal, 
making  the  production  of  "  anaphylaxis  "  possible. 

The  most  prominent  example  of  "  allergy  "  exists  in 
tubercular  individuals.  The  infection  with  the  tubercle 
bacillus  is  almost  universal  ;  but  a  prompt  immune  response 
puts  an  end  to  its  activity  early  in  life. 

However,  those  individuals  possessing  or  acquiring  idio- 
syncrasy  or   hypersusceptibility   to   the  proteins   produced 
during  the  immune  response,  are  subject  to  a  more  success- 
ful invasion  by  the  tubercle  bacilli.     For,  should  an  inva-  Hypersus- 
sion  occur,  —  whether  it  be  by  new  bacteria  or  an  extension  responsible" 
from  an  old  focus,  the  consequent  immune  response  giving  for  the 

i  .  i   '    i       i        •      i'     •  i        i    •  •!  •!!     development 

rise  to  the  protein  to  which  the  individual  is  susceptible,  will  Of  tuberculosis. 
produce  a  toxic  or  an  anaphylactic  effect.     This  effect,  when 
brought  about  by  an  artificial  immune  response,  is  better 
known  as  "  the  constitutional  reaction."     Such  a  constitu- 
tional effect  momentarily  lowers  the  resistance  of  the  individ- 
ual to  the  invader,  —  in  this  case  the  tubercle  bacillus  ;  and  so 
allows  of  its  multiplication  and  extension  into  the  tissues. 
Whereas,  in  most  of  the  common  infections  to  which  the 


TUBERCULIN  AND  VACCINE 


The  vicious 
cycle  in 
tubercular 
affections: 
The  protective 
response  pro- 
duces toxic 
protein  which 
allows  of 
extension  of 
the  disease. 


The  vicious 
cycle  is 
responsible 
for  the 
neglect  of 
tuberculin. 


The  aim  of 
this  book. 


human  race  is  subject,  we  aim  to  obtain  a  maximum  amount 
of  immune  response, — in  the  infection  with  the  tubercle  ba- 
cillus its  severity  depends  upon  the  greater  immune  response. 
The  vicious  cycle  in  tuberculosis  is  thus  made  plain.  The 
only  means  of  defense  against  tubercle  bacilli  is  the  immune 
response;  but,  owing  to  the  presence  of  hypersusceptibility, 
the  proteins  produced  by  the  immune  response  poison  the 
individual,  allowing  of  a  further  extension  of  the  disease. 
Thus,  a  vigorous  immune  response  which  is  curative  in  other 
diseases,  would  tend,  in  tuberculosis,  to  produce  the  active 
or  hasty  form  of  the  disease,  and  the  more  gradual  immune 
response  tends  towards  the  chronicity  of  the  process. 

So  it  has  come  to  pass,  that,  although  no  one  any  longer 
denies  that  tuberculin  is  capable  of  eliciting  an  immune 
response,  with  an  easily  ^demonstrable  hyperemia  in  the 
diseased  tissues,  it  has  been  abandoned  and  even  condemned 
in  the  treatment  of  tuberculosis. 

Fortunately,  there  is  an  increasing  number  among  the 
profession  who  have  learned  that  we  may  acquire  a  tolerance 
to  a  protein  poison,  and  overcome  the  individual  hypersus- 
ceptibility, if  we  produce  a  slowly  increased  amount  of  tol- 
erance by  means  of  a  gradual,  artificially  stimulated,  im- 
mune response,  with  the  degree  of  individual  hypersuscepti- 
bility as  an  index. 

The  principal  aim  of  this  book  is  to  emphasize  the 
necessity  of  overcoming  hypersusceptibility  and  to  advocate 
the  utilization  of  the  immune  response  in  tuberculosis,  and 
to  do  this  by  a  method  sufficiently  simple  to  become  prac- 
tical in  the  hands  of  the  general  practitioner.  For  it  is 
the  general  practitioner  alone  who  is  able  to  reach  the  great 
numbers  of  sufferers,  and  to  reach  them  in  the  earliest  stages 
of  the  disease.  Incidentally,  lest  our  successes  prove  often 
useless  to  the  afflicted,  I  have  added,  in  some  detail,  methods 
by  which  we  may  remove,  or  at  least  modify  the  results  of 
the  tubercular  affection,  obtained  before  the  patients  pre- 
sented themselves  for  treatment, — I  am  referring  to  the 
part  under  "  Special  Treatment." 


CHAPTER  II 
THE  NATURE  OF  TUBERCULINS 

The  specific  remedies  for  tubercular  affections  have  the 
same  aim  as  products  aiming  to  produce  immunity  in  all  Tuberculins 

.          .  .  .  are  modified 

other  affections ;  that  is,  active  immunity  and  passive  im-  vaccines, 
munity.     We  are  mainly  concerned  with  the  former.     The 
passive  form   consists  of   products  cropping  up   here  and 
there,  and  aiming  at  a  more  direct  attack  against  the  scourge, 
by  producing  passive  immunity. 

The  passive  method  of  immunity  in  tuberculosis  is  thus 
far  in  the  experimental  stage  and  nothing  brought  forward, 
up  to  this  time,  gives  any  promise  of  antitoxic  value.  How- 
ever, we  should  bear  in  mind  the  prevalence  of  the  disease, 
keeping  our  minds  open  to  conviction,  taking  account  of  Antitoxins  for 

tubercular 

every  product  that  may  be  brought  forward  through  scien-  affections  have 
tific  research,  in  order  not  to  overlook,  bv  too  hasty  iudg-  sofarno* 

•f     *          '      proved  effective. 

ment,  that  remedy,  which  through  the  induction  of  passive  However,  we 
immunity,  can  alone  solve  the  world-wide  problem  involved.  ™recon°eivedW 
We  must  not  allow  ourselves  to  forget  that  only  with  a  pas-  prejudice  to 

.7,      ;       ,  .    .  retard  the 

sive  immunizer  can  we  do  away  with  the  hypersensitiveness  progress  of 
in  tubercular  subjects  with  one  stroke,  and  either  cure  the  r 
patient  with  it  alone,  or  augment  the  treatment  with  an 
active  immunizer,  such  as  we  now  use,  without  the  fear  of 
reaction,  producing  the  same  results  as  we  are  now  obtaining 
with  vaccine  in  other  infections.      The  following  are  the 
three  most  important  antitoxins,  or  antitoxic  sera  that  have 
been  brought  out,  and  which  have  up  to  this  time  gained  the 
widest  publicity: 

Maradeano's  Serum.  Three  of  the 

most  important 

Marmorek's  Antituberculosis  Serum.  antitoxic  sera 

Hoechst's  Tuberculosis  Serum.  So°far. 

Each  of  these,  and  several  of  the  others  which  we  need  not 
mention  here,  have  raised  the  hopes  of  their  particular  inves- 


8 


TUBERCULIN  AND  VACCINE 


There  are 
three  main 

Tariations  in 
tuberculins. 


Old  Tuberculin 
OT  or  T. 


Tuberkulin 
obers  alt  TOA. 


tigators,  but  as  jet,  no  passive  immunizer  has  been  discov- 
ered which  can  be  recommended  for  general  use. 

Of  the  active  immunizers,  with  which  we  are  here  con- 
cerned, we  have  the  three  chief  forms  as  exemplified  by 
Koch's  original  work  and  which  still  represent  the  basis  of 
all  other  forms  and  modifications  subsequently  produced  by 
others.  These  products  consist  of  three  principal  varieties : 
(1)  the  soluble  .secretions  of  the  tubercle  bacilli,  (2)  the 
bacterial  bodies  alone,  and  (3)  a  mixture  of  the  two.  All 
other  preparations,  whether  derived  by  Koch  himself  or  by 
others,  merely  depend  on  the  method  of  preparation  or  con- 
centration, or  upon  the  method  of  sterilization  which  takes 
into  account  the  variations  in  the  extraneous  substance,  going 
into  the  solution  from  the  culture  media. 

Type  1,  or  Tubercular  Filtrates 

Koch's  OT,  AT  (alt  Tuberkulin)  or  T,  is  the  most 
familiar  and  best  example  of  this  type.  Its  method  of 
preparation  is  as  follows: 

Pure  cultures  of  tubercle  bacilli  are  grown  from 
four  to  six  weeks  on  a  5%  glycerine-broth.  This 
is  sterilized  with  the  culture  fluid  by  heating  for 
one  hour  in  steam.  This  is  filtered,  removing  the 
tubercle  bacilli  from  the  liquid,  which  is  now  con- 
centrated to  one-tenth  its  bulk  in  a  low  temperature 
oven. 

It  thus  consists  mainly  of  the  soluable  secretions  of  the 
tubercle  bacilli,  plus  a  small  amount  of  endotoxin,  which 
is  extracted  from  the  tubercle  bacilli  bodies  during  the  hour 
of  steam  sterilization,  owing  to  the  presence  of  alkali  and 
glycerine  in  the  medium. 

TOA  (Tuberkulin  obers  alt)  is  the  same  as  OT,  except 
that  it  is  not  concentrated  to  one-tenth  its  bulk.  When 
used,  it  is  merely  taken  in  ten  times  the  strength  as  OT,— 
using  a  ISTo.  4  dilution  where  No.  5  of  OT  would  be  used — 
and  so  on  throughout  the  dilutions.  Its  advantage  over  OT, 


9 

if  any,  consists  only  in  having  to  make  one  dilution  less  at 
the  beginning  of  the  treatment,  but  has  its  great  disadvan- 
tage at  the  conclusion  of  treatment,  when  a  full  c.c.  and 
then  2  c.c.  of  the  pure  TOA  would  have  to  be  administered. 
It  is.  however,  a  favorite  in  some  parts  of  Europe,  especially 
in  Switzerland. 

AF  (albumose-free  Tuberculin)  is  the  same  as  OT, 
except  that  the  bacilli  are  grown  in  an  albumose-free 
medium.  It  is  claimed  that  it  has  the  advantage  of  pro- 
ducing less  fever  during  a  reaction  by  the  removal  of  the 
albumose,  which  is  one  of  the  factors  in  producing  fever.  All>umose-free 

'  .  m  tuberculin  AF. 

It  would,  therefore,  be  well  suited  for  a  case  with  extreme 
hypersusceptibility,  at  the  beginning  of  treatment.  How- 
ever, it  is  extremely  difficult  to  get  a  constant  product, 
disastrous  results  having  occurred  during  treatment  by  a 
variation  in  its  strength.  And  it  is  doubtful  whether  the 
quantity  of  albumose,  during  treatment,  is  a  factor  at  all  in 
the  production  of  the  constitutional  reaction  and  so,  it  is 
best  to  leave  these  more  difficult  products  until  such  a  time, 
when  our  experience  will  allow  of  experimentation. 

Type  2,  or  Bacillary  Bodies 

The  dry  tubercle  bacilli  in  a  watery  emulsion  were  first 
used,  but  found  to  be  impracticable,  because  the  bacillary 
bodies  proved  to  be  non-absorbable  in  the  tissues,  and  soon 
formed  localized  abscesses.  Pulverization  of  the  dried  bacil- 
lary bodies  was  found  necessary,  and  so  the  best  example  of 
this  type  was  produced  by  Koch, — i.e.  BE  or  bacillary 
emulsion. 

The  tubercle  bacilli  are  removed  from  the  culture  Bacillus 

Emulsion  BE. 

medium  after  sufficient  growth,  carefully  washed, 
dried  and  then  pulverized.  An  emulsion  is  made, 
by  adding  one  part  of  pulverized  tubercle  bacilli, 
to  a  hundred  parts  of  a  solution  composed  of  equal 
parts  of  water  and  glycerine.  This  is  tested  for 
the  presence  of  living  tubercle  bacilli,  and  when 
found  sterile,  is  ready  to  be  used. 


10  TUBERCULIN  AND  VACCINE 

Tubercular  TK  and  TO   (Tubercular  Residue  or  New  Tuberculin 

New  Tuber-  and  Tubercular  Obers)  are  both  derived  during  the  process 
of  emulsifying  the  BE.  The  pulverized  tubercle  bacilli 

Tubercular  are  shaken  in  the  water  and  allowed  to  stand  until  they  fall 
in  a  sediment  The  water  is  decanted  from  the  top  and  used 
as  a  tuberculin,  which  is  designated  as  TO.  The  sediment 
is  emulsified  with  equal  parts  water  and  glycerine  in  the 
same  manner  as  BE,  and  is  designated  as  TR  or  new  tuber- 
culin. Both  of  these  were  found  extremely  inconstant  in 
strength  and  were  soon  abandoned. 

SEE  or  sensitized  BE,  or  as  manufactured  by  the  Hoechst 
Farbwerke,  under  the  name  of  "  Tuberkulose-Sero-Vakzin," 
is  an  attempt  to  remove  the  toxic  principle  of  the  tubercle 

sensitized  BE      bacilli  by  a  specific  amboceptor  (Antituberculin)  by  allow- 

S  B  E  or 

"  Tuberkuiose-    ing  the  pulverized  or  whole  tubercle  bacilli  to  remain  in 

Farb'Je^ke-"        contact  with   a   tubercular   serum.      Striking  results   have 

Hoechst.  been  obtained  with  this  sensitized  BE,  especially  in  animal 

experiments,  but  it  is  found  that  this  tuberculin  is  much 

more  active  than  any  of  the  others,  requiring  a  sixth  or  even 

seventh  dilution  at  the  beginning  of  treatment.     Besides 

the  drawback  of  being  much  stronger  in  its  effect  upon  the 

organism,  it  is  not  stable,  becoming  stronger  as  it  grows 

older;  and  it  is  also  very  expensive. 

Type  3,  or  Type  1  and  2  Combined 

Tubercuioi  The  best  example  of  this  type  is  Tuberculol  Landsmann. 

Landsmann  .      . 

a  good  example  This  is  prepared  by  making  a  BE  and  adding  this  to  the  fil- 
»f combined."  trate  w^^c^  nas  ^)eerL  concentrated  in  vacuo  as  far  as  possible. 
It  now  undergoes  a  process  of  filtration  through  porcelain 
candles,  and  after  the  addition  of  phenol  to  a  five  per  cent, 
strength,  it  is  diluted  until  1  c.c.  is  a  lethal  dose  to  a  guinea- 
pig  weighing  250  gnn.  A  more  detailed  description  of  the 
method  of  preparation  may  be  found — 
Landsmann.  Zentralblatt  fur  Bakteriologie,  Bd.  xxvii, 

1900. 

Hygienische    Rundschau,    1898    Nr.    10    u. 
1900,  Nr.  8. 


THE  NATURE  OF  TUBERCULINS  11 

This  tuberculin  has  the  advantage  of  being  absolutely 
constant  in  its  amount  of  tuberculin  reactivity,  as  every 
sample  is  tested  to  a  given  lethal  strength.  It  is,  however, 
highly  toxic  and  very  difficult  to  handle  in  the  beginning  of 
treatment.  If  used  at  all,  it  should  be  resorted  to  after  a 
high  degree  of  tolerance  has  been  acquired  through  the  use 
of  OT.  In  the  conclusion  of  treatment,  it  is  to  be  highly 
recommended  together  with  the  suggestion  of  Landsmann, 
that  the  final  dose  should  be  repeated  at  constantly  increas- 
ing intervals  for  a  considerable  period  of  time  in  order  to 
maintain  a  maximum  amount  of  tolerance  acquired  through 
its  use. 

Wolff-Eisner  directly  mixed  OT  and  TR.  Klebs  and 
Beraneck  (TBk)  have  made  similar  mixtures.  A  whole  byBeran 
series  of  preparations  have  been  made  by  Spengler,  mixing  others, 
the  OT  and  BE  in  different  proportions  intended  for  differ- 
ent grades  of  hypersusceptibility.  Gabrilowitsch  made  his 
"  Endotin  "  claiming  to  have  removed  the  toxic  substances 
from  tuberculin,  in  order  to  prevent  the  constitutional  febrile 
reaction,  but  all  these  merely  represent  tuberculins  made 
weaker,  for  it  is  the  amount  of  immune  response,  and  not 
the  toxic  substances  in  the  tuberculin,  which  is  responsible 
for  the  febrile  reaction. 

In  the  resume  of  the  principles  involved  in  the  various 
forms  of  tuberculin,  my  aim  has  been  to  allow  of  a 
glimpse  into  their  differences,  in  order  to  simplify  the 
matter  and  remove  the  idea  which  total  ignorance  of  these 
various  products  might  bring  about; — i.e.,  the  feeling  that 
there  may  be  something  still  better  than  what  we  are  already 
using,  so  that  we  shall  not  be  tempted  to  try  a  host  of 
different  preparations  without  having  given  any  one  a  fair 
trial.  As  I  have  said  before,  we  can  do  far  more  with  'a 
tuberculin  that  may  not  be  the  best,  but  with  which  we  have 
a  long  experience,  than  we  can  with  the  best  products  and 
with  constant  change. 


CHAPTER  III 
CHOICE  OF  TUBEKCULItf 

From  innumerable  investigations  and  from  reports  from 
different  clinics,  it  is  now  established  that  Old  Tuberculin 
is  distinct  from  other  tuberculins,  in  that  it  possesses  that 
element  which  brings  about  the  maximum  amount  of  toler- 
ance to  protein  poison  and  also  produces  a  maximum  amount 
of  focal  reaction  or  hyperemia. 

This  is  because  OT  does  not  contain  the  bacillary  bodies. 
Any  tuberculin  that  contains  the  bacillary  bodies,  seems  to 
bring  about  a  greater  immunity  against  the  tubercle  bacillus. 
OT  is  best  for      It  thus  produces  more  antibodies,  and  causes  disintegration 
Of  focal  of  a  larger  number  of  tubercle  bacilli.     Since  the  protein 

hyperemia.  poison  comes  from  the  tubercle  bacilli  thus  killed,  it  is  com- 
prehensible that  too  great  an  amount  of  poison  is  elaborated 
by  any  tuberculin  containing  the  bacillary  bodies,  making 
it  difficult  to  gain  tolerance  to  the  bacillary  poison,  and 
making  it  extremely  liable  to  severe  and  dangerous  reactions. 
OT  has  a  Old  Tuberculin  contains  a, minimum  amount  of  substance 

!maiiVamount       stimulating  the  formation  of  antibodies.     Hence,  it  can  be 
of  substance        safely  used,  because  we  can  more  easily  control  the  amount 

stimulating  .  .  . 

antibody  for-       of  antibodies  and  the  number  of  tubercle  bacilli  killed,  and  in 
that  way  we  can  control  the  amount  of  poison  these  lysinized 

easilx  tubercle  bacilli  form. 

We  must  not  lose  sight  of  the  fact  that  for  a  cure,  to  be 
complete,  bacillary  immunity  must  be  gained  as  well  as 
tolerance.  Consequently,  the  bacillary  bodies  are  of  great 
value  in  this  connection  after  OT  has  been  used  to  the 
optimum  dose;  a  dose  sufficiently  large  to  establish  the  fact 

Any  emulsion      fort  Wpersusceptibilitv  has  been  removed. 

of  tubercle  * 

baciiii  can  act  It  follows  that  the  ideal  choice  of  tuberculin  would  be 

"ccineCwhenr     to  use  ^  until  the  maximum  dose  is  reached,  at  which 
hypersuscepti-     point  the  patient  shall  have  acquired  complete  toxic  im- 

bility  is  . 

removed.  munitv  and  in  a  large  percentage  of  cases  complete  healing. 


CHOICE  OF  TUBEKCULINS  13 

Should  the  necessity  of  further  treatment  be  indicated, 
the  ideal  situation  is  present  for  the  use  of  a  bacillary  emul- 
sion. The  toxic  immunity  need  not  be  reckoned  with  any 
further  and  bacterial  immunity  can  now  be  established  in 
the  same  manner,  as  with  any  vaccine. 

Dilutions 

As  regards  the  making  of  dilutions,  as  simple  as  the    The  usual 

method 

matter  may  seem,  a  great  deal  of  confusion  is  produced  in  of  making 

the  minds  of  those  who  set  out  to  use  tuberculin.      This  compHcaTe'd  for 

confusion   is   caused    not   only  by   difference   in   methods  every-day  use. 
expounded,  but  also  by  the  standard  of  measures  used  in 
naming  the  quantities  of  tuberculin. 

Thus,   some  authorities  measure  by  weight,   others  by  There  should 

volume.      Now,    the   former   requires   a   knowledge   of  the  standard  of 

amount  of  the  solid   substance  in  the  specific   tuberculin  measufement 

for  tuberculins. 

used.  This  knowledge  is  difficult  to  obtain  in  a  great  many 
instances  and  very  often  varies  according  to  the  different 
authorities.  The  volume  of  the  tuberculin,  on  the  other 
hand,  always  remains  the  ^ame,  and  should  therefore  be  the 
standard  of  measure  in  making  dilutions. 

Again,  in  making  dilutions  in  multiples  of  ten,  one  easily   Make  ail  the 
reaches  the  highest  dilutions,  such  as  1  in  a  million,  or  1   theUrequ!red  ° 
in  ten-million,  without  the  least  difficultv.     This  method  is  one  instead  of 

'    .  „  ,.,,.,  attempting  to 

certainly  less  difficult  and  infinitely  more  accurate  than  at-  make  the 


tempting  to  make  the  dilution  which  one  requires  for  use 
directly. 

Again,  the  advice  given  for  the  luse  of  various  measuring 
glasses,  pipettes,  graduate  cylinders,  etc.,  adds  to  the  size 
of  the  mountain  in  the  imagination  of  the  beginner,  when   The  use  of  a 
only  a  mole  hill  is  in  question.     Since,  in  order  to  practice  tuberculin 
accuracy  in  tuberculin  treatment,  we  must  use  a  finely  sub-  syringe,  the 

i  •     >  i     i          i  i  •  ,  .  .  same  as  is 

divided  tuberculin  syringe,  why  not  use  the  same  syringe  used  in  treat- 

in  making  dilutions  and  thus  simplify  the  whole  process?  a^ednsi1mb1eesstt 

A  good  tuberculin  syringe  should  consist  of  all  glass,  or  an  for  dilutions. 
accurately   fitted   metal   piston   in   a   glass  barrel   holding 


14 


TUBERCULIN  AND  VACCINE 


y,  per  cent 
carbolic  in 
normal  saline 
is  best  as 
diluent. 


one  c.c.  divided  into  tenths  and  each  tenth  subdivided  into 
five  or  ten  parts.  Each  division  therefore  holds  0.1  c.c,, 
and  each  subdivision  holds  0.02  c.c.  or  0.01  c.c. 

The  diluent  used  in  making  the  dilutions  is  a  half  of 
one  per  cent  carbolic  in  normal  saline  (i.e.,  one  drachm  of 
a  5%  carbolic  solution  added  to  9  drachms  of  sterile  normal 
saline  placed  in  a  sterile  bottle).  This  may  be  used  until 
the  appearance  of  a  fungus,  when  fresh  diluent  should  be 
made. 


FIG.  1. — Tuberculin  all-glass  syringe. 


FIG.  2. — Tuberculine  record  syringe. 

Directions  for  Making  Dilutions 

Five  wide  mouthed  bottles  holding  about  a  dram  each 
should  be  numbered  1,  2,  3,  4,  5.  (See  Fig.  0.) 

Draw  into  a  tuberculin  syringe  0.9  c.c.  of  the  diluent 
followed  by  0.1  c.c.  of  the  tuberculin.  This  makes  the  first 
dilution.  Put  this  into  bottle  marked  1. 

Draw  in  0.9  c.c.  diluent  followed  by  0.1  c.c.  from  bot- 
tle 1.  This  makes  dilution  2  which  should  be  placed  in 
bottle  labeled  2. 

Draw  in  0.9  c.c.  of  the  diluent  followed  by  0.1  c.c  from 
bottle  2.  This  makes  dilution  3  which  is  put  into  bottle 
labeled  3. 

Draw  in  0.9  c.c.  of  diluent  followed  by  0.1  c.c.  from 
bottle  3.  This  makes  dilution  4  which  is  placed  in  bottle  4. 

Draw  in  0.9  c.c.  diluent  followed  by  0.1  c.c.  from  bottle 
4.  This  makes  dilution  5  and  is  put  into  bottle  labeled  5. 


CHOICE  OF  TUBERCULINS  15 

Special  stress  is  laid  on  the  drawing  of  diluent  into  the 
syringe  first,  followed  by  the  tuberculin  or  its  various  dilu- 
tions. There  are  two  good  reasons  for  this : 

First :  The  first  division  of  the  syringe  is  not  reliable 
and  varies  with  the  size  of  the  needle  or  the  shoulder  of  the 
syringe.  Thus,  measurement  of  the  tuberculin  will  not  be 
accurate. 

Second :  In  expelling  the  mixture  into  its  respective 
numbered  receptacle,  the  tuberculin  leaves  the  syringe  first, 
followed  by  the  diluent,  so  that  if  any  remains  in  the  needle 
or  shoulder  of  the  syringe,  it  will  be  diluting  fluid,  and  no 
tuberculin  will  be  lost.  This  will  also  obviate  the  necessity 
of  rinsing  the  syringe  after  each  dilution. 

Strength  Pure  Tuberculin  in 

Dilution  of  Dilution  each  c.c.  of  Dilution 

Xo.   1  contains  1  in  10  or  0.1  c.c.  or  100       c.rnm 

Xo.  2  contains  1  in         100  or  0.01  c.c.        or    10       c.mm 

Xo.  3  contains  1  in      1,000  or  0.001  c.c.      or      1       c.mm 

No.  4  contains  1  in    10,000  or  0.0001  c.c.    or      0.1    c.mm 

Xo.  5  contains  1  in  100,000  or  0.00001  c.c.  or      0.01  c.mm 

Stability  of  Dilutions 

A  diversity  of  opinion  seems  to  exist  regarding  the  sta- 
bility of  the  various  dilutions.     To  determine  exactly  the 
length  of  time  that  each  dilution  would  remain  active,  would 
not  be  at  all  worth  while.     It  would  involve  a  great  sacri- 
fice of  time  and  energy,  requiring  a  mass  of  laboratory  tests  Dilutions 
and  animal  experiments,  with  results  that  would  be  prac-  mad'J'f r«h  on 
tically  of  no  scientific  value.     The  only  value  would  be  the  day  of  use. 
from  an  economic  standpoint ;  and  this  is  a  very  insufficient 
reason  for  the  waste  of  time  and  effort,  as  the  cost  of  tuber- 
culin, when  made  up  in  dilutions,  is  insignificant.     Besides, 
as  is  made  evident  by  the  foregoing  methods  of  making  dilu- 
tions, there  would  hardly  be  a  saving  of  labor  for  those 
having  to  make  up  the  dilutions  for  treatment. 

I  take  this  occasion  to  condemn  the  use  of  prepared 


16 


TUBERCULIN  AND  VACCINE 


Ready  made 
dilutions 
should  be 
avoided. 


dilutions  put  up  at  distant  laboratories,  and  by  men  who 
are  not  in  touch  with  the  patients.  No  one  will  fail  to  feel 
a  degree  of  gratification  from  the  knowledge  of  tuberculin 
such  as  may  be  derived  from  the  handling  of  it,  and  to 
acquire  an  exactness  that  comes  with  making  one's  own 
dilutions.  After  making  these  dilutions  once  or  twice  the 
utter  simplicity  of  this  method  becomes  apparent. 

NOTE:  Solution  No.  1,  if  kept  two  or  three  weeks  in 
a  dark  cool  place  and  if  no  precipitate  forms,  will  remain 
stable  that  length  of  time.  It  is  well  to  keep  what  remains 
over  from  No.  1  dilution  until  just  before  making  the  next 
dilutions.  Occasionally  there  will  be  an  unexpected  delay 
in  obtaining  the  original  pure  tuberculin  and  the  left  over 
No.  1  can  be  used  in  such  an  emergency. 


II 


•     "3 


CHAPTER  IV 
THE  TUBERCULIN  REACTION  IN  DIAGNOSIS 

Following  the  tendency  of  all  things  to  go  in  the  direction 
of  least  resistance,  the  medical  profession  has  usually  tended 
to  avail  itself  of  the  easiest  way  and  the  nearest  elements  at 
hand  to  help  in  the  diagnosis  of  disease.  With  the  extended  The  ease  of 

j*i  T  i   •        •       T          •  -i        •  application 

use   oi    tuberculin,    this    inclination   may   result   in    a    too   should  not 
ready  employment  of  this  agent  as  a  means  of  diagnosis, —    Indiscriminate 
since  its  ease  of  application  !will  tempt  the  diagnostician  use  of  the 
much  more  readily  than  will  the  routine  of  physical  exam-  test. 
ination  or  the  examination  of  sputum,  systoscopic  examina- 
tion, catherization  of  the  ureters,  Roentgenographic  exam- 
inations or  other  means,  many  of  which  require  the  sending 
of  the  patients  to  a  distant  laboratory,  and  all  of  which 
demand  the  consumption  of  valuable  time. 

This  condition  may  lead  to  the  abuse  of  the  tuberculous, 
so  let  me  emphasize  at  the  outset  that  a  tuberculin  consti- 
tutional reaction  heightens  the  hypersusceptibility  of  the 
patient,  and  so  increases  the  difficulty  with  tuberculin  treat-  A  severe 
ment  in  proportion  to  the  severity  of  the  constitutional  reac-  reactumwiii 
tion  thus  brought  about.    As  far  as  the  local  tuberculin  reac-   increas« the 

,      .  „.         .  difficulty  of 

tions  are  concerned,  there  is -no  harm  in  their  utilization  tuberculin 

whenever  desired,  with  the  exception  of  the  conjunctival  test  t 

of  which  I  shall  speak  under  a  separate  heading.     But,  in 

the  case  of  a  test  which  requires  a  constitutional  reaction  for 

its  value  in  diagnosis,  tuberculin  must  be  used  only  as  a  whiiethe 

method  of  last  resort.     So  long  as  we  have  means  at  hand  to  are  harmless, 

establish  a  diagnosis  without  tuberculin,  so  long  should  we  the  c°nstltu; 

tional  reaction 

avoid  its  use.     By  adhering  to  this  maxim,  we  shall  make  as  a  test 
use  of  the  constitutional  reaction  in  diagnosis  only  in  the   utilized  as  a 
very  early  stages  of  the  disease,  where  all  other  methods  of  lastresort 
diagnosis  have  failed,  or  have  failed  to  produce  definite  find- 
ings.   We  shall  then  be  applying  it  in  cases  where  even  with 
a  severer  constitutional  reaction  the  damage  will  not  be  great. 
2 


18 


TUBERCULIN  AND  VACCINE 


The  ability  to 
recognize  the 
phenomena  of 
the  tuberculin 
reaction  will 
grow  with 
experience, 
thus  constantly 
increasing  the 
value  of 
tuberculin  in 
diagnosis. 


All  tuberculin 
reactions  have 
the  infallible 
quality  of 
detecting  the 
presence  or 
absence  of 
hypersus- 
ceptibility. 


hence 


Its  greatest 

importance 

will  be 

recognized 

when  an 

effective 

prophylatis 

will  obtain 

universal 

application. 


Once  the  proper  place  of  tuberculin  in  diagnosis  is  estab- 
lished, it  becomes  a  valuable  asset  in  our  hands;  for,  by  its 
means  we  shall  be  able  to  discover  early  processes  which 
have  been  impossible  of  discovery  without  tuberculin,  yet 
which,  when  discovered  are  the  most  amenable  to  the  tuber- 
culin treatment.  The  more  frequently  tuberculin  is  used 
in  diagnosis,  and  the  longer  the  phenomena  connected  with 
the  reaction  it  produces  are  studied,  the  greater  becomes 
its  value  in  the  diagnosis  of  tuberculosis  and  the  more  devoid 
of  any  damage  to  the  patient. 

The  tuberculin  reaction  is  essentially  a  reaction  to 
hypersusceptibility.  Whether,  as  I  shall  explain  further, 
any  one  of  the  methods  of  the  utilization  of  tuberculin  in 
diagnosis  enables  us  to  discover  an  active  lesion  or  not, 
it  is  certain  that  they  all  detect  hypersusceptibility  which 
means  the  presence  of  a  tubercular  lesion  healed  or  other- 
wise somewhere  in  the  body,  with  the  possibility  constantly 
present  of  an  extension  or  reawakening  of  the  process  some 
time  in  the  future.  This  is  why  the  tuberculin  method  of 
detecting  individual  hypersusceptibility  is  destined  to  be- 
come the  greatest  instrument  for  the  ultimate  prophylactic 
treatment  against  this  dread  disease,  for  it  will  be  the  means 
of  distinguishing  the  individuals  requiring  such  prophylaxis 
from  those  who  are  naturally  immune  to  tuberculosis. 

There  are  hundreds  of  reports  in  the  literature  of  tuber- 
culin such  as  those  of  Binswanger  and  those  from  the  army 
recruiting  stations  in  various  parts  of  Europe,  all  of  which 
leave  no  room  for  doubt  that  all  individuals  destined  to 
succumb  to  tuberculosis  would  be  found  by  means  of  a  tuber- 
culin test  to  possess  hypersusceptibility ;  whereas  the  natural 
immunity  exists  among  those  who  do  not  possess  such  hyper- 
susceptibility. 

Indication  for  Tests 

The  indications  for  the  use  of  the  tests  divide  the 
various  tests  into  two  groups.  The  tests  which  aim  to 
produce  a  localized  reaction  only  may  be  indicated  in 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  19 

any    case    and    may    be    used    as    often    as    desired,  —  for 

they  leave  very  little,  if  any,  effect  upon  the  patient.     The 

only  exception   is  the  conjunctival  test,  of  which  I  shall  special 

speak  later.     On  the  other  hand,  the  indications  for  the  need  be 

use  of  the  constitutional  reaction  in  making  the  test  should  co"slder«d 

only  in  the 

be  carefully  considered  before  it  is  applied.     Thus  it  should  case  of  the 

be  applied  only  as  a  last  resort  method  of  diagnosis,  and  test 
only  in  such  a  way  as  will  no.t  jeopardize  the  status  of  the 
case  with  reference  to  tuberculin  treatment,  if  it  should  be 
determined  upon. 

Interpretation  of  the  Tests 

Since  the  object  of  tuberculin  diagnosis  is  to  discover  other  phe- 

,.  ,        .  ,,  ..  ,     ,  T         •  nomena  occur- 

active  disease,   and   since  the   reaction  to  tuberculin  is   a  ring  during  a 

reaction   to   hypersusoeptibility   alone,   Iwe  must   take    into  reactlon 

account    other   manifestations    occurring   during   the    reac-  diagnostic  of 

tion  in  order  to  derive  the  full  benefit  of  the  diagnostic  except  i^very 

value  that  the  various  tests  possess.     In  the  case  of  the  young  children 

1-1  •  -11  T  j?  where  the 

localized  reaction,  we  can  consider  them  diagnostic  01  ac-  mere  presence 


tive  tuberculosis  only  in  such  cases  where  hypersuscepti-  s 

bility  must  exist  together  with  the  active  form  of  the  dis-   sufficient. 

ease  ;  in  other  words,  in  cases  where  the  process  had  no  time 

to  heal.     This  can  be  true  only  in  children  up  to  three, 

perhaps  four  years  of  age.     The  tubercular  process  when 

only  suspected  (thus  requiring  this  test)  is  bound  to  be  the 

first  process  attacking  the  child,  and  so  the  mere  presence 

of  hypersusceptibility  is  sufficient  to  establish  the  diagnosis  A  focal 

of  active  tuberculosis.     Under  these  circumstances,  any  test         '*"13 


bringing  about  a  local  reaction  alone  is  sufficient.     But,   even  with  the 
when  dealing  with  an  older  individual,  where  a  slight  lesion  constitutional 
healed  and  was  not  noticed  previous  to  the  present  suspected  r 
attack,  the  detection  of  hypersusceptibility  is  not  helpful 
in  the  determination  of  the  diagnosis.     Fortunately  how- 
ever mild  the  reaction  may  be,  there  always  occurs  a  hyper- 
emia  around  the  lesion  during  the  time  of  constitutional 
manifestations  of  the  reactions  and  thereby  renders  it  valu- 
able in  the  detection  of  an  active  lesion. 


20 


TUBERCULIN  AND  ^7'ACCINE 


The  focal 
reaction  or 
the  hyperemia 
can  only  occur 
in  the  tissue 
which  is  the 
seat  of  active 
disease, 
thereby 
increasing 
physical  signs 
and  symp- 
toms originat- 
ing in  such 
tissues. 


A  negative 

cutaneous  test 

obviates 

a  series  of 

subcutaneous 

tests. 


This  hyperemia  or  focal  reaction  as  it  is  called,  produces 
an  increase  of  the  inflammatory  process  in  the  lesion,  and  in 
that  way  exaggerates  any  symptoms  or  signs  which  its  locali- 
zation in  the  body  would  otherwise  produce.  Such  exaggera- 
tion is  all  that  is  necessary  to  remove  the  doubt  that  existed 
with  regard  to  the  nature  of  the  condition  that  made  the  test 
necessary.  Thus,  indefinite  physical  signs  at  the  apex  of  the 
lung  will  become  definite  during  the  constitutional  reaction. 
Rales  will  become  more  prominent,  dullness  more  definite, 
etc.  The  patient  will  complain  of  increased  cough  and 
expectoration.  During  this  time  the  sputum  may  show 
tubercle  bacilli,  whereas  before,  repeated  examinations  failed 
to  demonstrate  them.  Suspected  mediastinal  glands  may 
make  themselves  more  prominent  by  a  slight  swelling  that 
is  produced  with  a  focal  reaction  ,during  the  constitutional 
reaction.  Such  swelling  would  produce  pressure  in  the  chest, 
a  sensation  of  fullness  behind  the  sternum  and  even  dyspnea. 
The  hyperemia  produced  in  glands  of  the  neck  will  render 
them  more  tender  during  the  reaction,  thus  establishing  the 
fact  that  they  are  tubercular.  Urinary  symptoms  may  be 
increased  and  even  tubercle  bacilli  demonstrated  in  suspected 
genito-urinary  tuberculosis  during  a  constitutional  reaction ; 
and  so  on  through  the  list.  - 

The  fact  that  the  absence  of  hypersusceptibility  excludes 
a  tubercular  lesion,  might  make  it  advisable  to  establish  the 
fact  of  the  presence  of  hypersusceptibility  by  (the  simpler 
local  test  before  the  subcutaneous  *test  is  resorted  to.  In 
that  way  we  might  occasionally  spare  the  patient  hypodermic 
injections  of  tuberculin  by  ruling  out  hypersusceptibility. 


The  dose  of 
tuberculin 
generally 
advised  aims 
to  produce 
a  constitutional 
reaction  in  all 
cases  and  is 


Dosage 

In  a  constitutional  tuberculin  test  for  the  diagnosis  of 
tuberculosis,  the  subcutaneous  method  is  the  only  one  where 
the  consideration  of  the  amount  of  tuberculin  is  necessary,  as 
the  amount  of  tuberculin  used  in  the  localized  test  is  unim- 
portant. The  constitutional  reaction  varies  in  severity  in 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  21 

proportion  to  the  amount  of  tuberculin  used,  plus  the  degree  consequentiy 

too  large  for 

of  hypersusceptibility  present.  Most  writers  on  the  subject  some. 
of  tuberculin  diagnosis*  advise  a  dose  of  tuberculin  which  ex- 
perience has  shown  produces  a  constitutional  effect  in  all  cases 
where  a  tubercular  process  is  present.  They  give  consideration 
to  this  subject  with  only  one  aitm  in  view,  and  that  is,  to  pro- 
duce a  reaction  for  diagnostic  purposes  and  take  no  cogniz- 
ance at  all  of  a  contemplated  treatment  with  tuberculin  in 
case  the  test  establishes  a  diagnosis  of  an  active  lesion.  I 
believe  that  such  an  attitude  is  not  to  be  recommended  even 
without  the  contemplation  of  tuberculin  treatment;  for,  if 
a  constant  quantity  is  used  for  all  cases,  the  constitutional 
reaction  will  vary  in  proportion  to  the  degree  of  hypersus- 
ceptibility in  the  individual,  and  if  such  a  quantity  is  cal- 
culated to  produce  a  constitutional  reaction  in  an  individual 
with  a  small  amount  of  hypersusceptibility,  it  will  be  very 
severe  in  those  who  possess  a  higher  degree  of  hypersus- 
ceptibility. 

In  the  latter  case,  whatever  the  contemplated  treatment  The  severe 
may  be,  the  chances  for  recovery  in  such  an  individual  have  duced  during 
been  greatly  diminished.     Not  only  does  a  severe  constitu-  f  testhaye 

increased  the 

tional  reaction  produce  great  harm  to  the  afflicted,  but  helps  prejudice 
greatly  to  increase  the  prejudice  against  tuberculin  treat-  cun'n^reatmen 
ment;  for,  here  again  the  apparent  fault  in  the  production 
of  the  harm  is  with  the  tuberculin;  wrhereas  the  real  fault 
lies  with  the  quantity  of  tuberculin  used. 

Severe  reactions  have  also  helped  to  produce  an  array   contra- 
of  contraindications  to  the  tuberculin  test  which  should 


reallv  be  considered  as  centra-indications  to  severe  tuber-  constitutional 

i«  "  •  11  T      •         •  •  i          i  i  reaction  dis- 

culin   reactions,    and   when   a   limitation   is   placed   on  the  appear  with 
amount  of  constitutional  reaction  for  the  purpose  of  diag-  ™™ 


nosis,  —  all  these  contra-indications  will  lose  their  purpose,  dosage. 

When  a  patient  presents  himself  for  the  diagnosis  of 
tuberculosis,  and  the  importance  of  establishing  a  positive 
or  a  negative  diagnosis  is  explained,  it  will  be  a  great  excep- 
tion if  such  a  patient  object  to  two  or  three  or  even  four 


22  TUBERCULIN  AND  VACCINE 

tests,  especially  when  the  safety  of  such  a  procedure  and  the 
danger  of  the  single  test  method  is  pointed  out. 
The  quantity  ^he  amount  of  tuberculin  to  be  used  in  a  subcutane- 

of  tuberculin  . 

used  for  a  ous  test  should  be  no  more  than   ten  times  the  quantity 

diagnostic          j.     ^    used.  >  in    such    form    of  tuberculosis    as    is    recom- 

constitutional 

reaction  should  mended  as  the  beginning  dose  in  its  treatment.  (See  page 
23.)  For  example:  If  a  pulmonary  lesion  is  suspected  and 
0'10  C'C'  of  ^e  fifth  dilution  is  tne  dose  for  tne  beginning  of 


mentofthe  the  treatment  of  pulmonary  tuberculosis,  0.10  c.c  of  the 
fourth  dilution  should  be  the  quantity  of  tuberculin  used  as 
a  subcutaneous  inoculation  for  the  production  of  a  constitu- 
tional reaction  to  establish  the  diagnosis.  If  that  amount 
prove  insufficient  by  producing  a  negative  result,  the  test 
should  be  repeated  in  forty-eight  hours  and  five  times  the 
quantity  of  tuberculin  used  the  first  time  should  now  be 
inoculated  ;  that  is,  0.50  c.c.  of  the  fourth  dilution.  Should 
this  fail,  0.10  c.c.  of  the  third  dilution  should  be  used  in 
forty-eight  hours,  and  if  that  should  be  negative,  0.50  c.c.  of 

The  inoculation   ^he  {hirc[  dilution  used  is  as  a  fourth  inoculation.    As  a  final 

should  be 

repeated  every  test,  0.10  c.c.  of  the  second  dilution  should  be  given  forty- 

subsresquentry  eight  hours  later,  the  last  dose  being  the  one  recommended 

dose  should  usually  as  the  quantity  to  be  used  for  the  test.    If,  as  it  very 

greater  until  frequently  occurs,  there  is  a  reaction  from  the  first  dose,  the 

o^io  c.c.  of  the  temperature  rise  during  such  a  reaction  will  not  be  very 

2d  dilution  is  A  °  •> 

reached  and        marked,  with  the  constitutional  symptoms  even  less  marked. 

produces  no        But  how  would  such  an  individual  fare  with  the  last  dose 

ttstTs011  °^   tuberculin  which   is  one-hundred   times   the   quantity? 

negative.  Even  were  the  patient  to  react  to  the  fourth  test  for  the  first 

time,  this  would  be  brought  about  by  only  one-fifth  of  the 
quantity  usually  recommended,  and  to  inoculate  five  times 
the  quantity  that  would  suffice  to  produce  ,a  reaction,  is.  suffi- 
cient to  cause  a  dangerously  severe  reaction. 

Again,  it  may  be  argued  that  where  more  than  one  inocu- 
lation is  made  for  the  production  of  a  reaction,  the  tolerance 
gained  from  the  first  inoculation  may  prevent  a  reaction  from 
the  subsequent  ones  and  thus  exclude  the  diagnosis  of  tuber- 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  23 

culosis  where  it  might  exist  with  a  low  degree  of  hypersuscep- 
tibility.  Such  an  occurrence  is  prevented  by  making  the 
reinoculations  at  no  greater  interval  than  forty-eight 
hours.  Tuberculin,  when  given  in  such  increases  as  recom- 
mended for  the  test,  when  repeated  in  forty-eight  hours, 
rather  tends  to  superimpose  the  effect  of  one  dose  upon  the  The  serial 

.  -,  f         i  ....  .  test  thus 

other  than  to  gain  any  tolerance  lor  the  patient,  for  its  action  becomes  a 
does  not  stop  in  fortv-eight  hours.     On  the  other  hand,  with   ™easure  of 

individual 

this  method  of  producing  a  constitutional  reaction  for  diag-  hypersus- 
nosis,  we  hardly  jeopardize  the  good  effects  that  might  be 
obtained  with  tuberculin  treatment  in  the  event  of  a  positive 
diagnosis.  Another  great  advantage  that  may  be  derived 
from  such  a  method  of  eliciting  a  constitutional  reaction  for 
diagnostic  purposes  is  that  this  method  becomes  more  or  less 
a  measure  for  the  individual  hypersusceptibility  present,  so 
that  if  the  patient  does  not  react  to  the  first  three  doses  but 
does  to  the  fourth,  we  could  begin  treatment  in  this  case 
with  the  third  dilution  instead  of  with  the  fifth  and  so  save 
a  considerable  period  of  time  both  in  arriving  at  the  maxi- 
mum amount  of  tolerance  and  in  the  total  length  of  time 
required  for  the  treatment. 

Tables  of  Dosage  for  Subcutaneous  Tests 

Pulmonary 

OT   Dilution  No.  4  0.10  c.c. 

"         No.  4  0.50  c.c. 

"  "         No.  3  0.10  c.c. 

"  "         No.  3  0.50  c.c. 

"  "         No.  2  0.10  c.c. 

Bone  and  Joint  Tuberculosis 

and 

Uro-Genital  Tuberculosis 
OT   Dilution  No.  3  0.10  c.c. 
"  "         No.  3  0.50  c.c. 

"  "         No.  2  0.10  c.c. 


TUBERCULIN  AND  VACCINE 

Glandular  Tuberculosis  and  Lupus 

OT   Dilution  No.  2  0.10  c.c. 

"  "         No.  2  0.50  c.c. 

"  "         No.  1  0.10  c.c. 


The  principal 
contra-indica- 
tion  of  the 
tuberculin 
test  is  the 
possibility  of 
a  diagnosis  by 
other  means. 


Heart  disease 
is  no  contra- 
indication to 
the  milder 
reaction  pro- 
duced by  the 
above 
procedure. 


Nephritis  is 
a  contra- 
indication. 


Centra-indications 

There  are  no  contra-indications  to  the  local  tuberculin 
tests,  except  those  mentioned  in  connection  with  the  con- 
junctival  test.  There  is,  however,  an  ever  present  contra- 
indication to  the  use  of  constitutional  reaction  for  diagnosis 
and  that  is  the  possibility  of  making  a  diagnosis  by  any  other 
means.  It  is  far  better  to  begin  the  treatment  of  doubtful 
cases  and  form  the  conclusion  later  that  the  case  is  not  tuber- 
cular from  the  failure  of  obtaining  a  reaction  during  a  treat- 
ment, than  to  produce  a  severe  constitutional  reaction  in 
a  case  that  is  tubercular.  Other  contra-indications  are  as 
follows : 

Heart  disease.  Owing  to  the  disturbances  in  the  circula- 
tion produced  by  very  severe  reactions  in  isolated  instances, 
heart  disease  was  deemed  by  some  authorities  to  be  a  contra- 
indication to  the  tuberculin  test.  This  is,  however,  true 
only  of  the  very  severest  forms  of  heart  disease,  such  as 
myocarditis  or  fatty  heart  and  very  severe  valvular  diseases, 
in  which  conditions  it  makes  ivery  little  difference  in  practice 
whether  we  know  that  the  patient  has  tuberculosis  or  not; 
so  these  need  not  be  discussed  here.  The  milder  reaction 
obtained  by  the  divisional  injection  of  tuberculin  as  sug- 
gested above  will  produce  no  harm  whatsoever  in  the  ordi- 
nary form  of  heart  disease. 

Nephritis.  Nephritis,  we  must  consider  as  contra-indi- 
cating the  subcutaneous  test.  It  is  well  known  that  any 
febrile  reaction  produces  albumen  in  an  individual  with 
healthy  kidneys  and  it  is  therefore  far  better  to  treat 
a  case  with  tuberculin,  although  the  diagnosis  is  doubtful, 
than  to  run  the  risk  of  causing  permanent  damage  to  the 
kidneys,  which  are  already  the  seat  of  nephritis,  in  order 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  25 

to  be  sure  of  diagnosis  before  treatment.  It  is  well  to  state 
right  here  that  a  routine  urine  examination  should  be  made 
before  every  subcutaneous  test. 

Intestinal  ulceration-s.    During  convalescence  from  acute   The  suspicion 

,  -      .  ,  .  ...  of  tuberculosis 

disease  such  as  typhoid,  pneumonia,  peritonitis,  acute  ap-   inanuicera- 
pendicitis   and  gastric  ulcer,  where  a   tubercular  basis  to   twe  infectlous 

process  in  the 

these  ulcerations  may  be  suspected,   a  constitutional  reac-   alimentary 

canal  contra- 

tion  may  lead  to  too  great  a  focal  reaction  or  hyperemia,   indicates  the 

-,.  .  .  •    .L    i    •      j?  TIT  constitutional 

rendering  an  increasing  peristalsis  from  any  cause  liable  to   test 
set  up  a  fatal  hemorrhage.     Treatment  under  such  circum- 
stances is  not  inconvenient  for  the  patient,  for  the  suspicion 
of  tuberculosis  presupposes  too  slow  or  poor  convalescence, 
thus  requiring  visits  from  the  physician  anyway. 

Contagious   or  infectious  diseases  preceding  less  than  Theconstitu- 

.  i  •    •  >    •  i  •         •          ^  •  tional  reaction 

six  months  a  condition  requiring  the  constitutional  reaction   ;s  apt  to  be 
for    diagnosis,    absolutely  (  contra-indicate    a    subcutaneous   to°  se*' 

»  soon  after  con- 

tuberculin  test,   for  a  hypersusceptibilitv  following  conta-  ^e'^us  dis- 

eases even  by 
gious  diseases  in  children  or  any  acute  infection  whether  in   the  divisional 

child  or  an  adult  is  so  marked,  that  even  a  carefully  applied 
test  may  call  forth  a  very  severe  reaction. 

General  miliary  tuberculosis.     The  subcutaneous  tuber-  General  miiiar 
culiii  test  is  contra-indicated  where  general  miliary  tuber- 


is   SUSpected.  are  absolute 

contra- 

Epilepsy.     The  subcutaneous  tuberculin  test  in  epilepsy  indications. 
is  contra-indicated  no  matter  how  long  the  patient  has  been 
free  from  a  seizure  in  the  latter  trouble. 

Fever.    The  presence  of  fever  is  another  contra-indication  The  presence 
to  the  test;  as  a  patient  suffering  from  fever  more  or  less  indicates  th« 
distorts  the  mechanism  of  the  tuberculin  reaction,  a  foreign   subcutaneous 
injection  during  fever  may  merely  cause  a  higher  rise.     If 
a  patient  with  a  temperature  is  suspected  of  tuberculosis, 
treatment  of  that  patient  should  be  commenced  with  tuber- 
culin. because  as  said  elsewhere,  if  the  temperature  is  caused 
by  a  tubercular  process,  tuberculin  treatment  will  soon  act 
as  an  antipyretic  and  reduce  that  temperature.     The  tuber- 


TUBERCULIN  AA~D  VACCINE 


Hemopytsis  is 
so  constant 
an  indication 
of  pulmonary 
tuberculosis 
that  no  test 
is  required. 


culin  treatment  in  this  instance  could  do  no  harm,  should 
the  patient  turn  out  to  be  non-tubercular.  If,  however,  the 
patient  is  tubercular,  then  no  time  has  been  lost  in  applying 
the  tuberculin  treatment. 

Hemoptysis.  Recent  hemoptysis  in  case  of  suspected  lung 
tuberculosis  is  a  centra-indication  to  the  subcutaneous  tuber- 
culin test.  The  same  condition  holding  true  in  case  of  fever 
holds  true  in  a  case  following  recent  hemoptysis.  Careful 
treatment  with  tuberculin  is  indicated,  and  is  of  great 
importance  to  the  patients,  as  all  these  individuals  can  be 
classed  under  the  very  beginning  stages  where  tuberculin 
has  its  maximum  effect  A  lung  lesion  with  physical  signs- 
so  few  as  to  make  the  diagnosis  doubtful,  together  with  the 
fact  that  so  few  conditions  other  than  tuberculosis  produce 
hemoptysis,  makes  the  treatment  for  these  conditions  with 
tuberculin  absolutely  justifiable.  It  goes  without  saying 
that  before  beginning  treatment  of  such  an  individual,  the 
physician  must  make  sure  that  the  bleeding  was  not  from 
the  gums  pr  other  chronic  conditions  in  the  larynx,  pharynx, 
naso-pharynx  and  nasal  passages. 


A  second 
application  of 
the  cutaneous 
tests  is  advis- 
able in  order 
to  verify  a 
negative 
finding. 


Determination  of  the  Tuberculin  Test 

The  local  tuberculin  test  merely  determines  the  presence 
of  hypersusceptibility.  It  also  determines  the  presence  of 
a  previous  lesion,  except  where  the  individual  tested  is  too- 
young  to  have  had  a  previous  lesion.  The  negative  results,, 
however,  are  sufficient  to  exclude  the  presence  of  a  tuber- 
cular lesion,  taking  it  for  granted  that  the  tests  were  pro- 
perly carried  out.  In  order  to  be  certain,  it  is  advisable 
in  all  such  instances  fa  repeat  the  test  for  the  verification 
of  the  negative  finding.  In  the  case  of  the  subcutaneous 
test,  the  determination  of  the  positive  finding  will  rest  with 
the  presence  of  a  well  defined  focal  reaction. 

The  following  two  reports  are  but  examples  of  many 
such  investigations  with  no  less  striking  findings  made  in 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  27 

various  parts  of  the  world,  showing  the  absolute  specificity 
of  tuberculin  to  the  presence  of  hypersusceptibility  and 
tubercular  infection.  Incidentally,  they  emphasize  the 
fact  that  the  constitutional  reaction  is  absolutely  safe  and 
is  not  capable  of  rendering  a  closed  or  healed  lesion  active, 
in  spite  of  the  assertion  of  the  antagonists  of  tuberculin  that 
the  reaction  renders  the  tubercle  bacilli  "  motile,  causing 
reawakening  of  the  process,  spreading  the  disease  beyond 
its  original  focus." 

One  report  is  that  of  Binswanger  (Arch.  f.  Kinderheilk, 
1906,  Bd.  xl,  Heft  1-4).  Of  261  children  whom  he  injected, 
35  reacted.  Of  these  261  children  thus  tested,  42  came  sub- 
sequently to  post-mortem  examinations,  the  children  having  Report  of 
died  from  various  causes.  Of  these,  16  had  reacted  posi-  1 
tively  during  the  tests  and  were  now  all  found  to  be  tuber- 
cular. Of  the  remaining  26  who  failed  to  react,  25  were 
found  to  be  free  from  a  tubercular  lesion,  only  one  having 
any  sign  of  tuberculosis.  Even  this  one  did  not  prove  an 
exception  to  the  negative  finding,  as  the  injection  was  made 
in  the  fifth  week  of  its  life,  when  in  all  probability  infection 
had  already  taken  place,  but  !no  tubercular  lesion  had  yet 
time  to  form  until  after  the  test, 

Through  the  reactions  in  various  experiments  made  at 
army  recruiting  stations  in  different  parts  of  Europe,   it 
was  found  that  the  subcutaneous  tests  were  positive  in  from   Recruiting- 
30   to   60  per  cent,  of  pases.     Upon  investigation,   it  was   armyp°st& 
found  that  the  higher  per  cent,   were  found  among  those 
coming  from  areas  with  known  widespread  tuberculosis,  and  ' 
that  those  soldiers  coming  from  less  infected  areas,  showed 
the  smallest  percentage  of  positive  test.     The  two  points  to 
be  deduced  from  these  findings  are:  first,  the  absolute  spe-* 
cificity   of   the   tests;    second,    that   in  healthy   individuals 
the  subcutaneous  test  is  of  no  greater  value  than  the  cuta- 
neous test  and  the  percutaneous  test.     It  merely  points  to 
the  presence  of  tubercular  infection,  which  may  have  existed 
before  and  which  is  cured.     One  more  important  point  was 


28  TUBERCULIN  AND 

determined  by  these  tests  as  made  in  great  numbers:  that 
at  no  time  has  the  test  in  question  caused  a  reawakening  of 
a  former  lesion,  thus  emphasizing  the  findings  of  a  great 
many  authorities,  that  the  subcutaneous  test  is  not  harmful 
to  the  individual  with  healed  tuberculosis.  Hence,  we  can 
conclude  that  the  subcutaneous  tuberculin  test  has  all  the 
merits  of  the  other  tests,  plus  the  great  advantage  to  be 
gained  by  measurable  doses.  The  knowledge  of  the  exact 
quantity  absorbed,  when  figured  in  relation  to  the  reac- 
tion produced,  has  the  great  additional  advantage  of  help- 
ing to  determine  the  activity  and  the  extent  of  the  tuber- 
cular process.  Thus,  the  rapid  Reaction  to  small  doses,  indi- 
cates a  more  active  recent  disease,  whereas  slow  reaction  to 
repeated  increasing  doses  of  tuberculin  may  point  to  an  older 
chronic  process.  The  degrees  between  these  two  are  numer- 
ous and  have  to  be  determined  by  careful  observation  of  the 
patient's  history  and  clinical  manifestations  before  and 
immediately  following  the  test.  It  is  therefore  impossible 
to  lay  down  schematic  rules  for  the  determination  of  a  tuber- 
culin test. 

Cutaneous  Tests 

The  cutaneous  test  of  von  Pirquet  is  the  most  important 
and  most  widely  used. 

The  technique  is  very  simple;  the  flexor  surface  of  the 

forearm  is  preferred  both  on  account  of  the  absence  of  hair 

and  the  ease  with  which  the  findings  can  be  read.      The 

skin  is  rubbed  with  ether  and  scarifications  made  about  two 

Technique  of       inches  apart,  three  in  number  and  no  more  than  about  1/16 

test.  inch  in  diameter.     The  scarifications  can  be  made  with  an 

ordinary  needle,  but  great  care  must  be  token  not  to  pene- 

'trate  beyond  the  epidermis  in  order  not  to  draw  blood.     A 

moment  or  two  after  scarification,  a  slight  serous  moisture 

should  appear  on  its  surface.    The  flat  end  of  a  toothpick  is 

dipped  in  pure  old  tuberculin  and  rubbed  over  the  two  end 

scarifications,  using  a  separate  toothpick  for  each.     A  dry 

toothpick  is  used  in  the  same  manner  over  the  middle  scari- 


THE  TUBERCULIN  KEACTION  IN  DIAGNOSIS  29 

fication  so  as  to  produce  the  same  amount  of  trauma  on  all 
three.  The  scarifications  are  deemed  insufficient  if  a  tiny 
scab  does  not  form  over  each  in  an  hour  after  the  procedure. 
Bleeding  must  be  avoided  in  order  to  prevent  absorption 
of  the  pure  tuberculin;  for,  however  small  the  quantity,  it 
can  still  cause  a  constitutional  reaction  in  a  sensitive  indi- 
vidual. We  must  remember  that  hypersusceptibility  might 
exist  to  a  .very  high  degree  in  early  infection  even  though 
the  infection  may  be  so  mild  as  to  escape  recognition,  re- 
quiring this  test  for  a  diagnosis.  One  ten-thousandth  of  a 
cubic  centimeter  of  old  tuberculin  would  give  a  violent  reac- 
tion in  many  early  cases  of  pulmonary  tuberculosis,  and 
one  ten-thousandth  of  a  cubic  centimeter  of  pure  tuberculin 
is  so  minute  in  quantity  that  a  deep  scarification  would 
allow  of  its  ready  absorption.  The  middle  scarification  is 
the  control  scarification. 

Interpretation.     The  interpretation  can  usually  be  made  The  ful1? 
at  the  end  of  forty-eight  .hours,  when  the  maximum  effect  is  reaction  should 
developed.     However,  the  result  is  often  well  marked  in   ^e  looked  for 

during  the 

twenty-four  hours  and  very  rarely  takes  three,  five  or  eight  second  twenty- 
days  before  full  development  of  the  reactions  occurs.     We 
have  two  reactions, — the  traumatic  reaction  and  the  reaction 
of  hypersusceptibility. 

The  traumatic  reaction  occurs  over  all  three  scarifica- 
tions. It  consists  of  reddening,  with  a  formation  of  a  scab 
the  size  of  a  pinhead,  falling  off  in  about  twenty-four  hours, 
leaving  a  pale  brown  discoloration  behind. 

The  reaction  to  hypersusceptibility  or  the  positive  cuta-   care  should 
neous  reaction  has  a  latent  period  of  about  five  hours  to  distinguish  a 
several  days,  but  in  most  cases  it  develops  after  twenty-four  mild  reaction 
hours,  and  reaches  its  maximum  in  forty-eight  hours.     The  traumatic 
reaction  consists  of  an  exudate  and  a  hyperemia,  making  reactlon- 
itself  manifest  in  a  raised  reddening,  starting  from  the  scari- 
fication and  increasing  outward  until  it  reaches  a  diameter 
of  about  10  mm.     If  the  reaction  is  very  severe,  this  jnight 
reach  20  mm.  or  even  30  mm.  in  extent,  with  many  small 


30  TUBERCULIN  AND  VACCINE 

papules  forming  around  the  edge  of  the  reaction.  Even  a 
bluish-red  areola  might  appear  where  the  reaction  is  intense. 
After  forty-eight  hours  the  redness  begins  to  fade,  passing 
over  into  a  very  faint  violet,  leaving  a  slight  pigmentation, 
which  may  remain  visible  for  a  long  period,  and  Anally 
disappearing  with  a  slight  scaling  of  the  skin. 

Variations.  The  variations  in  this  reaction  are  innumer- 
able, depending  in  the  first  place  upon  the  state  of  hypersus- 
ceptibility  at  the  time  of  the  test,  the  stage  of  the  disease, 
and  the  general  circulation  of  the  patient.  Thus  an  anemic 
individual  will  show  a  paler  papule  than  one  with  good 
circulation;  and  a  well  nourished  individual  will  have  a 
larger  papule  with  .vesicles  better  marked  than  one  who  is 
emaciated. 

In  comparing  the  test  scarification  with  the  control  scar, 
one  must  allow  a  certain  degree  of  difference  even  for  a 
negative  result,  for  the  tuberculin  contains  irritating  mate- 
in  the  positive      r1^'  affecting  even  the  tuberculosis  free  individual.    This  fact 
vonPirquet         jjag  ]e(j  von  Pirque£  to  warn  the  profession  against  consid- 

vary.but  all 

are  diagnostic,  ering  a  local  papule  less  than  6  mm.  in  diameter,  as  a 
reaction,  even  though  it  looked  more  inflamed  than  the  con- 
trol scar.  In  case  of  doubt,  it  is  advisable  to  start  a  new 
test  on  the  other  arm  after  forty-eight  hours.  The  second 
test  will  be  decisive ;  for  it  is  an  established  fact,  that  even 
the  local  inoculation  of  tuberculin  will  increase  the  hyper- 
sensitiveness  of  a  tuberculous  individual,  and  will  render  the 
second  test  more  pronounced  than  the  first  test.  In  doubt- 
ful first  tests,  the  slight  increase  in  the  severity  of  the  second 
test  will  be  sufficient  to  decide  the  question.  The  increase 
in  the  second  reaction  is  far  more  diagnostic  than  the  ordi- 
nary test,  for  it  shows  a  universal  sensitization  of  the  organ- 
ism with  the  first  test;  and  it  has  been  frequently  shown 
that  tuberculin  cannot  sensitize  an  organism  perfectly  free 
from  tuberculosis. 

Negative  finding.    The  negative  finding  of  the  cutaneous 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  31 

test,   especially  of  the  second  test,   speaks  absolutely  for 

the  absence  of  tuberculosis  in  any  form.     The  following  Th_?.nesati™ 

3     finding  is  of 

exceptions  should  be  noted :    After  tuberculin  immunity  f ol-  the  utmost 
lowing  specific  treatment  in  individuals  suffering  from  gen-  value  in  the 
€ral  cachexia,   and  in  peculiar  skin  conditions.     In  those   tubercular0 
cases,  where  in  spite  of  demonstrable  tubercular  processes   inf«ction. 
this  reaction   is  negative,   there  are  either  spent  tubercle 
bacilli,  as  in  fungoid  fistulae,  or  suppurating  local  conditions, 
or  else  the  organism  has  lost  its  reactive  power.     This  last 
condition   von   Pirquet   explains    as   being  caused   by   the 
absorption  of  the  ergins  (the  bodies  which  cause  the  reaction 
between  the  tuberculin  and  the  cells)  preventing  tubercular 
allergin,  which  is  responsible  for  the  rapid  spread  of  the 
disease  in  those  individuals.    This  phenomenon  is  explained 
by  von  Pirquet  in  connection  with  negative  results  obtained 
in  children  suffering  with  the  measles  or  during  the  incu- 
bation period  of  scarlet  fever. 

This  explanation  fits  well  with  the  often  noticeably  rapid 
spread  of  an  otherwise  mild  tubercular  process,  following 
measles,  scarlet  fever  and  other  infectious  diseases;  also 
during  pregnancy.  Since  these  negative  findings  are  based 
upon  the  loss  of  the  immune  response  they  occur  only  in 
cases  of  evident  tuberculosis  and  do  not  lessen  the  value  of 
the  tuberculin  test  in  those  cases  where  the  establishment 
of  a  diagnosis  by  the  tuberculin  test  is  necessary. 

Positive  findings.     The  positive  findings  in  cutaneous 
tuberculin  tests  merely  point  to  the  fact  that  tuberculosis 
exists.     It  gives  no  clue  as  to  its  location,  nor  does  it  prove   The  positive 
its  clinical  existence.     This  fact  should  be  borne  in  mind,  diagnostic  value 
especially   when   testing   adult  patients.      A   positive  well    l".v,'jry young 
marked  reaction  should  put  us  on  our  guard  and  a  thorough 
search  should  be  made  for  a  tubercular  focus.     A  subcu- 
taneous test  to  bring  about  a  constitutional  reaction  seems 
best  indicated  under  these  conditions.     The  focal  manifes- 
tations during  a  constitutional  reaction  will  aid  greatly  in 
the  localization  of  an  active  process.     (See  page  40.) 


the  Moro  test. 


32  TUBERCULIN  AND  VACCINE 

In  children  up  to  the  fourteenth  year,  the  diagnostic 
indications  of  the  cutaneous  tuberculin  test  is  at  the  highest 
degree.  In  von  Pirquet's  clinic,  where  thousands  of  chil- 
dren have  been  tested,  97%  of  tubercular  children  gave  posi- 
tive reaction  or  showed  naked  eye  evidence  of  tuberculosis 
at  autopsy.  No  case  which  ever  gave  a  negative  result 
showed  any  gross  or  miscroscopic  signs  of  tuberculosis. 

Escherich's  Needle  Tract  Reaction 

This  reaction  is  practically  a  local  reaction,  such  as  we 
get  in  subcutaneous  tests.  The  recommendation  is  to  use 
0.20  c.c.  of  No.  3  dilution  in  the  subcutaneous  tissue  on 
the  flexor  side  of  the  forearm.  If  the  reaction  is  positive, 
a  red  spot  appears  sharply  circumscribed  and  quite  distinct 
from  the  red  areola  that  forms  around  the  needle  puncture. 
This  begins  in  about  six  hours  and  comes  to  its  height  in 
about  forty-eight  hours,  after  which  it  begins  slowly  to  dis- 
appear. Infiltration,  edema  and  great  tenderness  accom- 
panies this  reaction  as  a  rule.  When  no  general  reaction 
occurs  and  this  local  reaction  is  indistinct,  the  dose  may  be 
doubled. 

Elc5cUhe-s°f  The  indications  for  this  test,  as  well  as  its  positive  find- 

ings, are  the  same  as  for  the  von  Pirquet.  Its  disadvantage 
lies  in  its  much  greater  liability  to  produce  a  constitutional 
reaction.  It  therefore  should  not  be  given  preference  over 
the  von  Pirquet  It  should  be  used  only  after  a  doubtful 
von  Pirquet  for  confirmatory  purposes  where  the  technique 
of  the  von  Pirquet  was  uncertain  and  a  surer  entrance  of 
the  tuberculin  into  the  skin  is  required. 

Percutaneous  Tuberculin  Test  of  Moro 

Moro  used  inunctions  of  equal  parts  of  Koch's  old  tuber- 

•  j          .       , 


-.  •  j          .       , 

ilm  and  anhydrous  lanolin.  He  recommends  as  the  site  for 
the  inunction,  the  abdominal  wall  beneath  the  ensiform  car- 
tilage, or  the  skin  of  the  chest  above  the  nipple;  but  considers 
the  use  of  the  forearm  as  unsuitable  for  this  test.  A  quan- 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  33 

tity  of  the  ointment,  about  the  size  of  a  pea,  is  rubbed  for 
about  a  minute  with  the  index  finger  over  an  area  of  5  c.m. 
in  diameter  using  moderate  pressure.  A  protection  for  the 
finger  is  unnecessary,  as  the  surface  of  the  hand  or  finger 
does  not  react  to  tuberculin.  The  inunction  area  should  be 
exposed  to  the  air  for  a  few  minutes  and  no  further  atten- 
tion paid  to  it.  Dressing  is  unnecessary.  The  reaction  ap- 
pears both  as  to  time  and  grades  of  intensity,  in  the  same 
manner  as  with  the  cutaneous  test  of  von  Pirquet.  From 
the  mass  of  literature  on  the  subject,  there  can  be  no  further 
doubt  that  the  positive  reaction  is  absolutely  specific. 

There  is  no  contra-indication  to  this  test,  except  in  pro- 
nouncedly scrofulous  children.  Here  a  distant  cutaneous 
reaction  might  occur,  causing  great  discomfort  from  itching 
and  occasionally  seriously  affecting  for  the  worse  the  scrofu- 
lous process.  It  shows  a  great  many  less  positive  reactions 
in  known  positive  cases  than  the  von  Pirquet  test  and  has  Except  in 

,.-..      .-i  f  ,f  ,  mi         isolated 

not  the  advantage  01  limited  area  for  its  manifestation,     ihe  instances  this 
only  instance  where   it  might  be  advantageouslv  used   in  test .IS  mferior 

«*  "to  the  von 

preference  to  the  von  Pirquet,  is  in  a  case  where  the  physi- 
cian  does  not  wish  to  disclose  to  the  patient  the  nature  of  his 
test,  or  the  fact  that  he  is  testing  at  all.  For  instance,  there 
are  mothers  who  fear  an  inoculation  of  the  disease,  when 
the  inoculation  method  is  used,  leaving  the  Moro  test  as 
the  only  choice.  The  modifications  of  the  Moro  test,  such 
as  Lignieres'  and  Lautier's  are  much  inferior  to  the  original 
Moro  and  cannot  be  recommended. 


Intracutaneous  Tuberculin  Test 

The  intracutaneous  tuberculin  test  consists  of  the  injec-  Technicof 

,,  »  — TS — ^  i  .  ••          .-i  the  intra- 

tion  oi  a  quantity  ol  tuberculin  into  the  skin,  and  under  no  cutaneous  test 
circumstances  should  the  injection  be  deep  enough  to  make 
it  hypodermic.  The  place  chosen  should  be  the  thigh,  arm 
or  inner  side  of  the  forearm.  A  fold  of  skin  is  raised,  the 
needle  puncture  is  made  flat  in  the  skin  and  is  pushed  paral- 
lel with  the  fold  for  a  very  short  distance.  Solution  No.  3 
3 


TUBERCULIN  AND  VACCINE 


The  positive 
reaction 
develops 
during  the 
second  24  hrs. 
reaching  its 
maximum 
in  48  hrs. 


The  danger 
of  a 

constitutional 
reaction  and 
the  great 
discomfort  it 
often  produces, 
render  it 
inferior  to  the 
von  Pirquet. 


of  old  tuberculin  is  used  and  such  quantity  injected  as  will 
raise  a  white  wheal  about  %  to  3/16  of  an  inch  in  diameter. 
The  white  wheal  disappears  in  about  20  minutes,  and  noth- 
ing remains  visible  except  perhaps  the  needle  puncture,  until 
the  positive  reaction  sets  in,  which  is  in  about  five  to  six 
hours,  reaching  its  maximum  within  forty-eight  hours. 

Commencing  with  a  slight  infiltration,  appreciable  only 
to  touch,  the  infiltration  increases  until  it  reaches  about 
an  inch  in  diameter,  surrounded  by  an  inflammatory  area, 
which  sometimes  reaches  in  extent  to  the  size  of  the  palm  of 
the  hand.  In  the  center  of  the  infiltration  appears  a  reddish, 
sometimes  edematous  area,  with  an  erythematous  edge. 
The  area  may  be  covered  with  small  red  papules;  or,  when 
the  reaction  is  severe,  actual  blistering  occurs.  After  forty- 
eight  hours  the  infiltration  begins  to  subside,  inflammatory 
symptoms  begin  to  diminish  and  in  a  few  more  days  the 
mark  disappears  nearly  entirely  with  the  scaling  of  the  skin. 
The  hard  infiltration  may,  however,  persist  for  weeks.  If 
the  test  is  negative,  only  a  very  slight  indur.ation  with  the 
faintest  brown  coloration  occurs,  disappearing  in  about  two 
days ;  and  since  positive  reaction  would  reach  its  height  by 
that  time,  there  is  no  difficulty  in  recognizing  it,  even  if 
very  mild. 

This  factor  is  the  favorable  feature  of  the  intracutaneous 
tuberculin  test  But  Angel's  claim  that  it  produces  no  dis- 
comfort is  disputed  by  a  great  many  authorities  who  have 
used  this  test  extensively.  My  own  observation  found  that 
the  positive  reaction  produces  great  discomfort  with  in- 
ability to  use  the  arm  for  several  days;  also  a  definite  con- 
stitutional effect  has  often  appeared,  including  focal  reac- 
tion, such  as  enlargement  of  tubercular  glands  of  the  neck. 
The  general  effect  of  the  intracutaneous  test  is  the  same 
as  the  cutaneous  one,  with  the  added  disadvantage  of 
greater  intensity  of  its  action.  However,  it  can  be  used 
with  advantage,  where  the  cutaneous  test  is  negative,  on 
account  of  the  control  of  the  quantity  of  tuberculin  used  in 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  35 

the  test;  thus,  Angel  recommends  the  use  of  1 :5000  dilution 
first,  1:1000,  1:100  and  finally  1:10.  This  test  is  also  of 
value  where  the  subcutaneous  test  is  contra-indicated  and 
the  cutaneous  test  has  proved  negative.  However,  the  sphere 
of  this  test  cannot  be  extended  beyond  that  of  the  cutaneous 
test,  and  seems  to  be  limited  to  early  childhood,  rendering 
its  fields  of  usefulness  extremely  small. 

Conjunctival  Tuberculin  Test 

This  test  was  discovered  by  Calmette  and  Wolff-Eisner, 
as  a  modification  of  the  von  Pirquet  test,  and  was  reported 
under  the  names  of  "  ophthalmic  reactions  "  and  "  conjunc- 
tival  reactions."  The  latter  name  is  more  appropriate,  as  Technicof 

*'.  •*  the  conjunctiva! 

the  reaction  occurs  in  the  conjunctiva  only.  Special  tuber-  test, 
culms  were  at  first  deemed  necessary ;  but  according  to  Ban- 
del  ier  and  Roepke  and  others,  the  original  Koch's  old  tuber- 
culin is  the  best.  It  obviates  the  difficulty  of  obtaining  the 
special  kind  and  is  a  great  deal  less  expensive  (95%  alcohol 
precipitate  of  tuberculin  dried  and  sold  in  small  ampules,  a 
watery  solution  to  be  made  at  the  time  of  use).  The  tech- 
nique is  very  simple.  An  ordinary  dropper  can  be  used,  a 
single  drop  of  one  to  four  per  cent,  of  old  tuberculin  in 
adults,  and  a  half  to  one  per  cent,  in  children.  The  drop  is 
placed  in  the  conjunctival  sack,  care  being  taken  that  the  end 
of  the  dropper  does  not  touch  the  sack  and  cause  a  flow  of 
tears,  or  movements  of  the  lids  that  may  expel  the  tuberculin. 
The  tuberculin  is  now  kept  a  minute  or  two  in  the  closed  eye 
and  no  further  attention  necessary;  no  bandage  or  eye  pro- 
tection is  required. 

The  reaction  begins  in  from  five  to  six  hours  and  usually 
comes  to  its  height  in  about  twenty-four  hours,  remaining 
visible  for  several  days  afterwards.  The  reaction  grades  from 
a  reddening  of  the  conjunctiva,  which  can  only  be  seen  on 
everting  the  lid  and  comparing  it  with  the  other  side,  to  a 
reddening  of  the  entire  conjunctiva  visible  from  a  distance. 
In  severe  cases,  swelling,  much  fibrinous  or  purulent  secre- 


36 


TUBERCULIN  AND  VACCINE 


This  test 

should  not 

be  used 

as  even  its 

negative 

finding;  has  no 

diagnostic 

value. 

It  is  also 

dangerous 

to  the  eye. 


Hypersus- 
ceptibility 
may  remain 
in  the  con- 
junctiva after 


tion,  and  even  echymosis  may  appear.  -These  tests  may 
be  repeated  two,  three  and  four  times  and  it  is  advisable  to 
begin  with  a  much  weaker  solution  than  is  usually  used  in 
order  to  avoid  the  severer  form  of  the  conjunctival  reaction 
in  hypersensitive  individuals.  Begin  with  the  \%  solution 
and  increase  to  2,  3  pnd  4%  in  the  subsequent  tests.  It  is 
also  advisable  to  use  each  eye  alternately,  as  the  severe 
forms  of  reaction  occur  in  patients  where  an  overlooked  posi- 
tive reaction  in  a  conjunctiva  has  increased  the  hypersensi- 
tiveness  of  that  conjunctiva  and  caused  the  reaction  from 
the  second  installation  to  be  very  severe. 

The  specificity  of  the  test  is  beyond  doubt  as  true  of  the 
conjunctival  test,  as  it  is  of  the  cutaneous  or  intracutaneous 
test.  However,  this  test  cannot  be  recommended,  for  not 
only  is  it  often  dangerous,  causing  severe  damage  to  the 
eye,  but  its  negative  finding  is  not  reliable,  as  over  fifty 
per  cent,  of  early  active  tuberculosis  have  shown  negative 
reactions  in  the  hands  of  many  investigators.  Special 
warning  should  be  taken  against  the  use  of  tuberculin  in 
a  conjunctiva  that  has  been  the  seat  of  a  positive  reaction, 
no  matter  what  length  of  time  intervened.  This  warning 
also  applies  to  the  use  of  a  conjunctival  test  following 
a  cutaneous  or  subcutaneous  test,  before  the  hypersus- 
ceptibility  awakened  by  these  tests  has  entirely  subsided. 
Under  no  circumstances  should  a  cutaneous  or  subcutaneous 
test  be  made  before  a  conjunctival  test  has  entirely  subsided, 
as  the  increased  susceptibility  produced  by  the  cutaneous  and 
subcutaneous  tests  might  reawaken  the  conjunctival  reaction 
and  cause  a  very  severe  reaction  in  the  conjunctiva. 

It  can  thus  be  seen  how  a  positive  conjunctival  test  may 
interfere  with  the  necessary  therapeutic  tuberculin  inocu- 
lations. Once  the  conjunctiva  has  been  rendered  sensitive, 
it  may  severely  jeact  after  each  dose  of  tuberculin  even 
though  the  quantity  may  not  be  sufficient  to  cause  a  constitu- 
tional reaction.  I  have  now  under  my  care  a  little  girl  nine 


THE  TUBERCULIN  KEACTION  IN  DIAGNOSIS  37 


years  of  age,  who  has  been  treated  for  tubercular  adenitis  for   »  test  causing 

recurrence  of 
conjunctivitis 


over  a  year  without  marked  success.     A  conjunctival  test  r 


was  made  in  order  to  determine  the  nature  of  the  glandular  after  every 

tuberculin 

involvement  and  proving  positive  was  sent  to  me  for  tuber-  inoculation 
culin  treatment.     At  present  I  have  the  greatest  difficulty   for  treatment- 
in  gauging  the  ;dose  of  tuberculin,  as  the  slightest  approach 
to  maximum  tolerance  causes  a  severe  conjunctivitis.    Above 
all,  we  must  take  special  heed  that  every,  possible  eye  disease 
be  excluded  before  a  conjunctival  test  is  undertaken. 

Subcutaneous  Tuberculin  Test 

As  in  the  case  of  a  local  test,  the  subcutaneous  test  is 
also  a  specific  reaction  to  hypersensitiveness  on  the  part  of 
the  individual, — the  difference  being  in  the  degree,   as  a 
constitutional  reaction  also  takes  place,  due  to  the  absorp- 
tion of  the  tuberculin   in  this  method   of  administration. 
As  a  direct  result  of  the  tuberculin  inoculation,  as  given  in   Several 
this  form  of  the  test,  we  get  a  focal  reaction  at  the  point  of^hepatien* 
of  the  disease,  which  phenomenon  reveals  the  place  of  in-  are  necessary 

before  the  test, 

fection  and  to  a  greater  or  lesser  degree  the  activity  of  the  in  order  to 

,  ,  , .  .   ,       ,   .  ,         recognize  the 

process.  Care  must  be  taken  to  distinguish  this  reaction  by  focai  reaction, 
becoming  thoroughly  acquainted  with  the  condition  previous 
to  the  injection.  It  is  safe  in  the  hands  of  the  practitioner, 
provided  the  divisional  method  of  administration  is  resorted 
to,  as  herein  described,  so  as  not  to  produce  too  violent  a 
reaction  with  an  active  lesion. 

A  description  of  a  detailed  technique  for  a  subcutaneous 
inoculation  would  seem  superfluous  as  every  physician  has 
had  experience  with  the  hypodermic  syringe.  Still,  when 

we  consider  for  a  moment  that  an  individual  will  have  to  Techmcof 

the  sub- 
submit  to  a  large  number  of  inoculations,  anything  that  the  cutaneous 

, .  .  ,  ...  i      .  tuberculin 

physician  can  do  to  eliminate  pain  at  the  time  01  inoculation  test. 
or  prevent  severity  of  a  local  reaction  that  may  be  brought 
about  by  a  greater  traumatic  reaction,  will  be  desirable. 
In  this  connection    two    important   points    are   worthy    of 


38  TUBERCULIN  AND  VACCINE 

mention.  First,  have  the  arm  where  the  inoculation  is 
given  in  such  p.  position  that  the  needle  easily  penetrates 
the  skin,  and  the  physician  ,  is  able  to  tell  that  the 
point  of  the  needle  is  in  the  subcutaneous  .tissue.  Sec- 
ond, the  tuberculin  should  not  enter  intracutaneously, 
thereby  avoiding  an  undue  amount  of  traumatic  reaction. 
Both  these  objects  can  be  accomplished  by  rendering  tense 
the  skin  through  which  the  needle  must  penetrate.  It  will 
then  (feel  las  if  the  needle  penetrates  a  membrane  entering 
a  vacant  space  beyond  which  is  the  subcutaneous  tissue. 
The  best  way  to  render  the  skin  tense  is  by  grasping  the 
arm  from  behind,  drawing  all  the  tissues  backwards,  as 
shown  in  the  illustration.  (Fig.  6.) 

This  will  be  found  to  be  an  improvement  over  the  usual 
method  of  pinching  up  the  skin  when  giving  a  hypodermic 
injection.  Pressing  the  tissues  together  makes  it  impossible, 
at  times,  to  tell  whether  the  needle  has  penetrated  into  the 
muscular  layer. 

It  is  also  advisable  to  bear  in  mind  that  the  finest,  gauged 
needles  can  be  used  and  that  the  points  must  at  all  times 
be  sharp  especially  where  there  is  a  (tendency  to  leak- 
age from  the  puncture  in  the  skin.  Such  an  occurrence 
may  sufficiently  vary  the  amount  of  tuberculin  absorbed  to 
produce  a  sudden  severe  constitutional  reaction  during  the 
treatment.  The  loss  of  tuberculin  from  such  oozing  may  be 
very  small  in  amount  or,  it  may  even  amount  to  the  entire 
dose  given.  It  is  therefore  necessary  to  guard  against  such 
an  occurrence  by  placing  the  cotton  tipped  applicator  (or 
toothpick)  dipped  in  iodine,  over  the  point  of  puncture 
immediately  upon  withdrawing  the  needle.  The  same  appli- 
cator that  was  used  in  painting  the  small  area  of  skin  with 
iodine,  preparatory  to  inoculation  may  be  used.  It  need  not 
be  dipped  again  in  the  iodine  before  this  procedure,  as  a 
second  application  of  iodine  to  the  same  spot  may  cause  local 
irritation  on  a  tender  skin,  especially  if  the  iodine  happens 


FIG.  6. — THE  SUBCUTANEOUS  TUBERCULIN  TEST. — The  skin  is  rendered 
tense  by  drawing  the  tissues  towards  the  back  of  the  arm  with  the 
left  hand,  while  plunging  the  needle  with  the  right  hand  through 
the  center  of  the  area  painted  with  iodine. 


THE  TUBERCULIN  REACTION  IN  DIAGNOSIS  39 

to  be  old.  (Fig.  7.)  The  applicator  is  held  there  for  a 
moment  or  two,  using  a  little  pressure,  a  drop  of  collodion 
being  placed  over  the  needle  puncture  after  withdrawal  of 
the  applicator.  Massage  after  a  tuberculin  inoculation 
should  never  be  resorted  to,  as  it  is  desirable  to  have  the 
absorption  of  the  tuberculin  take  place  as  slowly  as  possible 
from  the  point  of  inoculation. 

In  the  event  reinoculation  is  necessary,  it  should  be 
made  at  a  considerable  distance  from  the  former  inocula- 
tion, as  a  local  reaction  may  take  place  in  the  tissues  that 
have  been  somewhat  sensitized  from  a  previous  inoculation, 
where  such  a  reaction  would  not  have  taken  place  otherwise. 
The  result  of  this  would  be  a  false  finding.  It  is  better  still 
to  use  each  arm  alternately  for  repeated  inoculations. 

SYMPTOMS  OF  THE  TUBERCULIN  REACTION 

The  principal  elements  in  the  general  reaction  elicited 
from  a  subcutaneous  injection  consists  of  the  three  principal 
elements  :  local  reaction,  the  constitutional  or  febrile  and  the 
focal  or  lesion  reaction. 

Local  reaction.    The  most  frequent  symptom  of  a  general  A  hardened 

.....  m1  .  nodular 

reaction  is  the  reaction  at  the  point  01  injection.     Ihis  con-   induration  at 


sists  of  a  painful  swelling  at  the  site  of  the  injection,  with  the 

inoculation 

an  infiltration  of  the  subcutaneous  tissue  to  various  degrees  constitutes 
around  it.  So  frequent  is  the  occurrence  of  a  local  reaction  reaction. 
in  a  general  reaction,  that  its  non-occurrence  usually  throws 
doubt  upon  the  interpretation  of  the  rise  in  temperature  as 
a  general  reaction.  One  must,  however,  be  careful  in  the 
search  for  a  local  reaction,  for  it  sometimes  occurs  in  the 
subcutaneous  tissue  without  producing  superficial  redness, 
and  only  careful  feeling  over  the  point  of  injection  will 
reveal  the  small  subcutaneous  indurated  mass.  (Fig.  8.) 
Constitutional  reaction.  With  the  constitutional  mani- 
festation of  this  reaction,  we  have  a  disturbance  of  the  gen- 
eral health,  by  symptoms  pf  varying  degrees.  The  severe 
forms  begin  with  a  rigor,  followed  by  sensation  of  heat  or 


40  TUBERCULIN  AND  VACCINE 

The  constitu-       by  a  cnill  with  an  intense  headache,  accompanied  by  malaise, 

tional  reaction  .    .  .., .   .      .  j?   11  1 

resembles  in  dizziness,  nausea  and  even  vomiting.  Ihis  is  soon  iollowed 
influeT«.°the'  by  pains  in  the  limbs,  dragging  or  a  sensation  of  pressure  in 
symptoms  tne  affected  part,  accompanied  by  loss  of  appetite,  thirst, 

disappearing 

in  a  surprisingly  palpitation  and  sleeplessness.  All  these  symptoms  dis- 
appear with  a  fall  }in  temperature,  leaving  a  feeling  of  weak- 
ness lasting  a  day  or  two.  All  these  symptoms  Jast  a  sur- 
prisingly short  time,  considering  their  severity  and  nearly 
all  symptoms  disappear  within  forty-eight  hours.  The  vari- 
ability in  the  constitutional  symptoms  is  great  and  depends 
entirely  upon  the  individual  constitution.  Thus,  we  may 

The  constitu-  have  a  very  high  rise  in  temperature,  to  103  or  104,  without 
the  least  subjective  manifestation,  or  we  may  have  a  tem- 

reactionusu-       perature  rise  of  only  one  degree  with  the  severest  subjective 

during  the  symptoms.  When  carefully  conducted,  there  should  be  no 
appearance  of  extreme  constitutional  symptoms  and  the  tem- 

t'on-  perature  should  never  rise  above  two  degrees.  The  usual 

appearance  of  a  reaction  takes  place  during  the  second  twelve 
hours  following  the  inoculation.  However,  it  sometimes  ap- 
pears as  early  as  four  or  five  hours  (after  inoculation  and 
occasionally  does  not  appear  before  thirty  to  thirty-six  hours 
after  inoculation. 

The  focal  Faced  reaction.    The  focal  reaction  is  the  distinguishing 

is  the  feature  of  the  subcutaneous  tuberculin  test.  It  not  only 

determines  the  presence  of  active  tuberculosis  and  its  extent, 

teaturc  ot  * 

the  test.  but  very  often  helps  to  determine  the  location  of  the  tuber- 

cular processes,  which  remained  undiscovered.  For  instance, 
tenderness,  which  did  not  exist  before  will  appear  over  a 
beginning  affection  of  the  spine  during  the  tuberculin 
reaction;  tenderness  over  the  sternum  with  a  feeling  of 
pressure  in  the  chest  will  reveal  as  a  result  of  focal  reaction, 
tubercular  thoracic  glands,  on  account  of  their  swelling. 
A  focal  reaction  is  a  transitory  increase  of  the  inflammatory 
process  in  ,the  tubercular  area  and  its  manifestation  will 
bring  out  the  symptoms  which  go  with  an  inflammation  of 
the  particular  organ  which  it  affects. 


FIG.  7.— THE  SUBCUTANEOUS  TUBERCULIN  TEST.— The  needle  is  not  with- 
drawn until  the  applicator  with  cotton  on  the  end  is  placed  over 
the  injected  area,  ready  for  the  pressure  to  be  put  over  the  puncture 
on  withdrawal  of  the  needle,  to  prevent  loss  of  tuberculin  through 
oozing. 


FIG.  8. — THE  SUBCUTANEOUS  TUBERCTJLIX  TEST. — The  local  reaction  as 
it  appears  in  the  majority  of  instances  and  designated  on  the  Treat- 
ment Charts  as  moderate. 


THE  TUBEBCULIN  REACTION  IN  DIAGNOSIS  41 

Treatment  of  constitutional  reaction.     Regarding  treat-  Treatment  of 

.  .  thecon- 

ment  of  the  reaction,  only  a  few  words  are  necessary.    For  stitutionai 
the  severe  forms,  rest  in  bed,  with  perhaps  one  or  two  doses  sympto 
of  the  coal  tar  products  for  severe  headache,  is  all  that  is 
necessary.     I  warn  particularly  against  the  use  of  anti- 
pyretics,   as   we   want   the   highest   point   of   temperature 
revealed.     In  less   severe  forms,  there  is  no  necessity  of 
keeping  the  patient  in  bed,  avoiding  manual  labor  or  tiring 
exercise  is  sufficient. 


CHAPTER  I 
EQUIPMENT 

Although  it  has  been  my  aim  in  writing  this  book  tq 
simplify  the  treatment  of  tuberculosis  to  the  greatest  possible 
degree,  there  are  certain  details  so  essential  to  the  success 
of  the  treatment,  that  one  has  to  familiarize  himself  with 
them  at  once  and  give  them  his  closest  attention.  I  have 
endeavored  to  set  these  down  under  a  separate  chapter  before 
going  into  the  matter  of  the  treatment  of  the  various  forms 
of  tubercular  affections  in  order  to  show  at  a  glance  all  that 
is  necessary  to  begin  with. 

I  have  come  to  the  conclusion  that  it  is  not  sufficient  to 
merely  make  mention  of  these  various  items  dispersed 
throughout  a  work  of  this  kind,  as  in  this  way  important 
details  will  very  often  be  overlooked  and  so  lead  to  much 
embarrassment  and  to  complete  abandonment  of  this  impor- 
tant treatment.  Again,  the  amount  of  detail  will  be  seen 
to  be  far  less  burdensome  if  put  down  and  explained  at  the 
outset,  than  if  it  has  to  grow  upon  the  reader  during  the 
theoretical  and  practical  discussions  of  the  various  phases 
in  the  treatment  In  fact,  after  a  careful  perusal  of  this 
chapter,  it  will  be  noticed  how  simple  after  all,  the  arma- 
mentarium of  the  practical  immunizator  need  be. 
The  simplest  As  regards  the  more  elaborate  paraphernalia  described 

equipment  .  -i-ii  .-,.. 

possible  is          in  other  works — these  were  suggested  with  the  specialist  in 

ThtncetMtty       m*n<*  an<*  were  PromPte(l  D7  &  desire  for  completeness  of 
for  more  their  discussion.     One  may  take  advantage  of  these  susr- 

elaborate  ,  .  J         p 

equipment          gestions  alter  the  treatment  of  several  patients  when  the 
we  win  leave       whole  subject  will  no  longer  be  new  and  the  mysteries  sur- 

tor  experience  » 

to  discover.         rounding  it  will  have  vanished.    These  suggestions  represent 
the  refinements  that  come  with  experience,  rather  than  the 


EQUIPMENT  43 

actual  requirements  of  the  condition.  And  since  they  only 
help  to  complicate  the  subject  from  the  beginner's  point  of 
view — I  thought  it  wiser  not  to  touch  upon  the  more  com- 
plicated equipment  in  this  work. 

Proper  Record  Sheets  or  Cards 

No  one  should  attempt  to  use  tuberculin  or  vaccine  with- 
out keeping  a  careful  record  of  the  amount  and  date  of  each 
dose  with  the  results  following  each  dose ;  the  weight  of  the 
patient  and  a  record  of  various  other  data,  such  as  laboratory 
findings,  X-ray  findings  and  other  data  during  treatment  of 
the  patient.  A  chart  in  the  form  of  a  folder  (thus  having  four  Pr°p«r 

records  are 

pages)  can  have  the  history  and  diagnosis  on  the  first  page,  essential. 
The  second  page  can  be  properly  ruled  for  the  record  of  the 
tuberculin  administrations.  This  page  should  be  ruled  in 
eight  parallel  columns,  the  first  for  the  date,  the  second  for 
the  number  of  the  inoculation,  the  third  for  the  number  of  the 
dilution  used,  the  fourth  for  the  quantity  of  tuberculin  inocu- 
lated, represented  by  the  amount  of  the  particular  dilution ; 
two  columns  for  reactions,  one  for  the  local  and  the  other 
for  the  temperature;  the  seventh  column  for  the  weight 
record  and  the  eighth  for  miscellaneous  remarks.  (See 
Fig.  9,  page  45.)  The  sheet  may  be  large  enough  to 
accommodate  a  double  series  like  this  on  the  one  side  of 
the  folder,  and  will  thus  have  room  for  100  treatments, 
which  is  more  than  sufficient  in  most  instances.  Page  three 
is  divided  into  two  parts,  one-half  for  additional  notes  and 
the  other  half  as  a  record  for  other  medication.  Page  four 
can  be  used  for  the  record  of  vaccines  for  mixed  infections. 
Within  the  folder  can  be  kept  various  laboratory  reports, 
X-ray  photographs  and  temperature  charts.  The  whole 
sheet  is  made  of  heavy  paper  and  measures  15 1/2  inches  in 
length  and  8  inches  in  width  and  is  so  folded  that  the  right 
hand  sheet  is  one-half  inch  wider  than  the  left,  allowing 
the  half  inch  to  be  visible  for  the  name  and  diagnosis,  and 
for  filing  purposes.  During  treatment  it  may  be  filed  under 


44  TUBEBCULIN    AND    VACCINE 

the  name  ,of  the  pa.tient  and  after  the  treatment,  it  may  be 
compiled  under  the  form  of  the  disease. 

It  is  difficult  to  conceive  how  any  physician  would  fail  to 
keep  the  proper  records  when  treating  a  condition  with  tuber- 
culin, for  every  dose  is  figured  from  the  preceding  doses 
under  any  form  of  tuberculin  administration.  Even  were 
he  able  to  remember  all  the  quantities  injected  over  a  period 
of  months,  it  is  reasonable  to  suppose  that  no  one  would 
prefer  burdening  his  memory,  to  the  simple  procedure  of 
writing  down  a  quantity ;  still,  the  following  is  an  example : 
The  patient,  a  little  girl,  eight  years  old,  with  a  tubercular 
knee  joint  The  physician  commenced  treatment  of  this 
child  with  tuberculin  after  a  single  visit  to  my  clinic  at 
the  Xew  York  Polyclinic  Hospital.  After  five  months'  treat- 
ment, the  physician  died.  The  father  of  the  child  wrote 
to  me  asking  whether  I  would  continue  the  treatment  of  his 
little  girl.  My  answer  was  in  the  affirmative  and  I  requested 
that  he  bring  a  record  of  all  the  treatments  the  child  had 
received  up  to  that  time.  The  following  is  a  transcript  of 
the  letter  that  he  brought  to  me,  written  by  the  former  assist- 
ant, and  successor  to  the  physician:  I 

Dear  Mr.  L. 

Here  is  a  record  for  A.,  as  per  your  request. 
Do  not  remember  how  many  times  we  omitted  the 
injection  of  the  tuberculin,  as  we  did  not  make  a 
record  of  it — only  the  calls. 

Feb.    2 

Mar.  6-23-27 

Apr.   5-7-12-15-21-25 

May  2-6-10-13-16-20-24-27 

Jun.   3-8-13-19-23 

Hoping  this  will  be  satisfactory,  I  am, 

Yours  very  truly,  Dr.  X. 

It  is  needless  to  state  that  the  child  had  not  improved  in 
that  time  and  the  father  expressed  great  disappointment 
over  the  fact,  as  he  was  led  to  believe  that  the  child  would 


EQUIPMENT 


45 


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FIG.  10—  TubercuUn  record  page  of  the  record  folder  used  by  the  author. 

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46  TUBERCULIN  AND  VACCINE 

be  cured  in  from  six  to  eight  months.  It  might  also  be  men- 
tioned here  that  no  temperature  record  of  the  child  had  ever 
been  kept  during  the  treatment;  and  the  father  expressed 
surprise  when  he  was '  instructed  to  keep  such  a  record  and 
told  that  we  could  not  treat  the  child  without  the  temperature 
being  taken  after  each  inoculation. 

Syringe 

The  use  of  the  proper  syringe  will  obviate  the  necessity 
for  a  study  of  the  metric  system  in  case  one  is  noti  familiar 
in  it.  I  have  found  in  my  teaching  that  quantities  measured 
in  any  other  way  than  minims  and  drams  were  meaningless. 
The  everlasting  question  when  a  quantity  of  tuberculin  is 
mentioned  in  the  lecture  is :  "  How  many  minims  is  that  ?  " 
But  the  minim  measurement  is  out  of  the  question  in  the 
administration  of  tuberculin,  as  we  cannot  give  parts  of 
minims  and  one  minim  is  equivalent  to  approximately  0.06 
c.c.,  which  is  three  times  the  amount  of  increase  advised 
at  the  beginning  of  treatment.  The  further  diluting  of 
each  dilution  to  make  a  minim  equivalent  to  0.02  c.c.  will 
complicate  the  subject  a  great  deal;  whereas,  with  little 
trouble,  one  can  obtain  the  proper  syringe.  The  Record 
tuberculin  syringe  is  the  best  for  general  use.  It  holds  one 
cubic  centimeter,  which  is  divided  into  ten  large  divisions. 
Each  large  division,  which  holds  a  tenth  of  a  cubic  centi- 
meter, is  subdivided  into  fifths,  each  small  division  there- 
fore holds  one-fiftieth  or  0.02  c.c.  Whether  one  understands 
the  metric  system  or  not,  one  merely  measures  the  dose  by 
drawing  into  the  syringe  the  amount  desired,  the  reading  of 
that  quantity  is  on  the  barrel  of  the  syringe.  All  glass 
syringes  that  are  made  in  this  country  are  even  more  finely 
subdivided,  each  division  holding  0.01  c.c.  Difficulties  are 
sometimes  experienced  with  these  syringes,  owing  to  the  slip- 
ping of  the  piston  in  the  barrel.  This  has  to  be  guarded 
against  by  pressure  with  bne  finger  on  the  piston  where  it  en- 
ters the  barrel.  Rome  of  these  syringes  are  now  provided  with 
a  metal  spring  for  that  purpose,  (See  Fig.  1,  page  14.) 


EQUIPMENT  47 

Needles 

Since  tuberculin  is  not  very  viscid,  the  finest  gauged  The  needles 
needles  should  be  used.      This  is  important, — on   account 
of  the  large  number  of  inoculations  necessary  during  treat- 

,..,.,,  .  f  order  to  avoid 

ment,  making  it  desirable  to  avoid  as  much  discomfort  as  traumatic 
possible  to  the  patient  and  to  prevent  traumatic  reactions.  reactlon- 
A  platinum-irridium  needle  may  be  used,  as  its  advan- 
tage over  the  plain  needle  is  that  it  can  be  sterilized  in 
the  flame.  But  where  an  all  glass  syringe  is  used,  a  crack- 
ing off  of  the  screw  end  or  slip  end  of  the  syringe  very 
often  occurs.  The  plain  25-gauge  needles  one  inch  long, 
are  inexpensive,  can  be  readily  obtained  and  serve  the  pur- 
pose as  well  as  any  other  needles  made.  The  syringe  and 
needles  are  sterilized  in  alcohol  and  rinsed  with  the  diluting 
fluid  before  treatment. 

Office  Scales 

All  office  balance  scales  will  do  for  weighing  the  patients,  office  scales 
A  physician  should  not  depend  upon  his  patients'  weighing 
outside  and  bringing  in  their  weight  for  record.  It  is  sel- 
dom that  a  patient  will  take  the  trouble  to  remember  the 
difference  in  clothes  between  each  weighing ;  whereas,  in  the 
office  one  can  weigh  the  patient  right  after  the  inoculation. 
One  can  always  follow  a  given  routine  in  the  office  for 
weighing  patients  in  order  to  have  any  extraneous  influences 
eliminated. 

Containers  for  Dilutions.     (Figs.  3  and  4.) 

Any  bottles  holding  a  little  over  a  cubic  centimeter  are 
suitable.  If  the  bottles  are  so  large  as  to  prevent  the 
needle  from  reaching  the  bottom,  the  mouth  of  the  bottle 
must  be  large  enough  to  admit  .the  circumference  of  the 
syringe.  These  bottles  may  be  sterilized  by  allowing  them 
to  remain  over  night,  filled  with  95  per  cent,  alcohol.  This 
alcohol  must  be  rinsed  out  with  diluting  fluid  before  mak- 
ing dilutions.  Small  squares  of  adhesive  plaster  may  be 


48 


TUBERCULIN  AND  VACCINE 


Aside  from 
instructions 
as  to  taking 
of  temperature, 
it  is  best  to 
limit  the  first 
consultations 
to  the  diag- 
nosis of  the 
disease. 


At  the  sub- 
sequent visit, 
all  instructions 
as  to  hygiene, 
diet,  etc., 
should 
be  given. 


used  in  labeling  the  bottles.  A  cool,  dark  place  for  the 
storage  of  the  tuberculin  and  vaccines  completes  the  equip- 
ment. 

Instructions  to  Patients 

Aside  from  the  usual  instructions  as  to  hygiene,  diet 
and  fresh  air, — details  into  which  we  need  not  go  here, — 
the  patient  should  be  instructed  in  the  regular  taking  of 
temperature  four  times  daily:  at  eight,  at  twelve,  at  four 
and  at  eight  o'clock,  for  at  least  three  or  four  days,— 
and  should  be  taught  to  keep  a  pareful  record  of  it.  No 
other  instructions  that  refer  to  tuberculin  treatment  need 
be  given  at  the  (first  consultation.  The  patient's  mind  is 
diverted  entirely  to  the  realization  of  his  condition;  and 
any  other  discourse  or  instruction  will  lose  its  force  if  given 
at  the  same  time  with  the  diagnosis.  However,  the  carry- 
ing out  of  the  instructions  for  taking  temperature  will  pre- 
vent in  a  measure  the  brooding  and  worry,  and  will  add  to 
his  confidence  in  the  physician. 

At  the  second  visit,  the  patient  should  be  told  the  mean- 
ing of  immuno-therapy ;  he  should  be  told  that  tuberculin 
administered  twice  weekly  will  stimulate  his  own  protective 
processes,  helping  him  in  that  way  to  overcome  his  disease. 
The  prejudices  existing  against  tuberculin  must  be  men- 
tioned to  the  patient,  so  that  if  they  have  not  reached  his 
ears  before,  his  confidence  in  tuberculin  during  treatment 
should  not  be  lessened  by  what  he  may  hear  from  outside 
sources.  It  must  also  be  explained  that  these  prejudices 
were  brought  about  by  the  faulty  administration  of  tuber- 
culin, and  that  with  a  more  careful  technique,  tuberculin  is 
devoid  of  danger.  It  must  be  especially  emphasized  to  the 
patient  that  the  treatment  must  be  brought  to  a  conclusion 
when  once  it  is  begun,  as  an  interruption  of  the  treatment 
before  maximum  tolerance  is  reached  will  often  lead  to  a 
rapid  retrogression  of  the  condition.  This  retrogression  fol- 
lowing upon  a  too  early  discontinuation  of  treatment  has 
often  been  laid  to  the  tuberculin  itself.  Indirectly,  it  may 


EQUIPMENT  49 

be  true;  for,  just  as  the  sudden  discontinuation  of  stimu- 
lants in  heart  disease  may  sometimes  cause  a  sudden  col- 
lapse of  the  heart  muscle ;  so  also  in  tuberculosis,  when  the 
healing  process  depends  upon  outside  stimulation,  which 
when  prematurely  discontinued  will  cause  sudden  retro- 
gression. We  must  therefore  continue  the  treatment  with 
tuberculin  to  the  point  of  maximum  tolerance  and  then  for 
a  period  of  time,  determine  at  regular  intervals  whether  the 
maximum  tolerance  is  being  maintained.  (See  Tri-Monthly 
Tests,  page  147.) 

The  patient  must  also  be  made  to  understand  that  the  The  patient 

i      '     '  •  ft  i-         -i  it    must  be  a 

proper  administration  01  tuberculin  depends  a  great  deal  wining 
upon  his  own  assistance:   that  he  is  a  "partner"  in  the  Partnermthe 

treatment  to 

treatment,  and  therefore  must  take  his  temperature  regu-  insure  its 
larly  every  two  hours,  on  the  day  of  the  inoculation  and  the 
day  following  it.  He  must  note  as  far  as  possible  any  focal 
manifestation  and  mention  it  to  the  physician  when  he  next 
presents  himself  for  treatment.  The  focal  manifestations 
must  be  explained  as  an  increase  in  the  various  signs  and 
subjective  symptoms,  and  the  patient  must  note  how  long 
this  increase  persists  after  the  inoculation,  so  that  we  may 
be  able  to  differentiate  between  an  actual  focal  reaction  and 
a  retrogression  in  the  disease,  due  perhaps  to  insufficient 
tuberculin. 

It  is  by  far  better  to  instruct  the  patient  to  take  rectal 
temperature,  if  convenient.     However,  if  that  be  impracti- 
cable, and  the  mouth  temperature  must  be  depended  upon, 
the  patient  should  be  instructed  to  make  certain  that  the 
mercury  column  in  the  thermometer  is  shaken  down  below 
95°  before  taking  the  temperature  and  that  he  keep  it  under 
his  tongue  for  at  least  five  minutes  by  the  clock,  even  if  the 
thermometer  be  a  "  one-minute  "  thermometer.     The  physi- 
cian need  not  expect  to  meet  with  any  difficulties  in  the  car-  ™."e™°* 
rying  out  of  his  instructions  w'ith  regards  to  temperature,   patient  can 
If  he  insist  that  the  treatment  will  depend  upon  the  proper  k^aane  c 
taking  of  temperature  and  will  absolutelv  refuse  the  treat-  accurate 

"  .  temperature 

ment  if  the  patient  pleads  ignorance  in  the  matter,  it  is  record. 


50  TUBERCULIN  AND  VACCINE 

surprising  what  ability  will  be  displayed  along  this  line 
by  the  most  ignorant  patients.  It  was  said,  when  I  first 
established  a  clinic,  that  if  my  treatment  depended  upon  the 
taking  of  temperatures  by  the  patients,  the  whole  project 
would  prove  a  lailure,  for  the  class  of  patients  who  apply 
for  treatment  at  the  New  York  Polyclinic  Hospital  consists 
mainly  of  the  ignorant  foreign  element.  In  spite  of  that 
assertion,  the  clinic  has  grown  larger  in  size  and  every  patient 
who  gets  the  treatment  brings  on  paper  his  temperature  suc- 
ceeding his  last  treatment.  It  is  a  matter  of  comment  to  see 
what  surprisingly  neat  temperature  records  these  patients 
bring.  The  difficulty,  if  met  with,  consists  of  the  inability 
on  the  part  of  the  patient  to  get  the  focus  upon  the  mercury 
column  in  the  usual  magnifying  thermometer.  The  plain 
thermometer  without  the  magnifying  glass  can  be  obtained 
through  any  druggist  and  will  remove  the  only  difficulty  in 
the  way  of  the  patients  reading  the  temperatures. 

In  ambulatory  cases,  I  have  avoided  complicating  the 
treatment  from  the  standpoint  of  the  patient  by  refraining 
from  the  distribution  of  printed  slips,  requiring  the  answer 
to  many  questions  concerning  pulse,  respiration,  headache, 
pain  in  the  limbs,  pain  in  the  joints,  malaise,  sleeplessness, 
fatigue,  restlessness,  nervousness,  indigestion,  nausea,  vomit- 
ing, chilliness,  rash,  enlarged  glands,  and  a  host  of  other 
questions  which  are  printed  on  slips  and  distributed  among 
patients  in  many  clinics.  I  am  quite  certain  that  seventy- 
five  per  cent,  of  the  answers  are  influenced  by  the  con- 
centration upon  the  symptoms.  It  is  quite  sufficient  to  ask 
the  patient  at  the  time  of  his  visits  whether  he  has  coughed 
more  or  less,  whether  he  brought  up  an  increased  amount 
of  sputum  or  whether  there  was  a  noticeable  decrease; 
whether  the  amount  of  discharge  from  a  sinus  is  markedly 
increased  as  shown  by  the  amount  of  increase  of  dressings 
required  and  whether  this  discharge  is  thinning  or  becoming 
thicker ;  and  in  a  case  of  glands,  whether  they  have  become 
more  swollen  or  less  swollen,  or  more  painful  or  less  painful, 
and  so  on  through  the  different  varieties  of  tuberculosis. 


CHAPTER  II 
TUBERCULIN  TREATMENT 

The  methods  of  treatment  with  tuberculin  resolve  them- 
selves into  three  distinct  classes:  the  reactive  method,  the 
non-reactive  method  and  the  combination  of  the  two.     The 
reactive  method  is  the  one  that  Koch  originally  used,  and 
has  but  few  remaining  adherents  at  the  present  day.     It 
consists  of  giving  a  dose  sufficient  to  cause  reaction,  and 
continuing  with  the  same  dose  every  third  or  fourth  day ; — 
each  time  producing  the  same  reaction.     The  sudden  col- 
lapse of  tuberculin  therapy  that  marked  the  first  tuberculin 
era  was  brought  about  by  this  treatment,  as  disastrous  results 
overtook  the  largest  majority  of  patients  treated  by  this  The  three 
method.     The  fear  that  overtakes  most  physicians  at  the  tuberculin 
suggestion  of  tuberculin  therapy  has  been  instilled  by  this  *?emt£e:stratioa 
method  of  treatment;  a  fear  which  the  great  majority  of  reactive, the 
physicians  try  to  mask  by  condemnation.     Why  base  this  ™nd  thl  one*' 
condemnation   on   ignorance   and   hearsay,   instead  of  dis-  that  combine* 
pelling  it  by  investigation  and  fair  trial  ?    We  must  remem- 
ber that  this  method  of  treatment  was  born  of  a  desire  to 
find  a  remedy  for  so  important  a  disease  as  tuberculosis 
before  the  hypersusceptibility  existing  in  this  disease  was 
known  and  the  desire  for  an  immunizer  was  so  great  that  its 
use  was  attempted  far  too  generally  before  its  true  nature 
was  understood.      The  disappointment  that  soon  followed 
was  consequently  so  intense  that  condemnation  of  tuber- 
culin took  the  place  of  further  study  and  investigation. 

Fortunately,  there  were  a  few  investigators  who  were 
quick  to  recognize  the  indication  of  its  virtues  and  who  con- 
tinued the  use  of  tuberculin  and  evolved  the  second  method 
of  treatment;  the  non-reactive  method.  It  was  quite  a 
natural  outcome  to  revert  to  minute  doses  after  the  larger 
doses  had  proved  unsuccessful.  The  minute  dose  was  used 
in  the  same  way,  as  the  larger  dose  was  used,  merely  inocu- 


52  TUBERCULIN  AND  VACCINE 

The  minut*         lating  at  three  to  seven-day  intervals,  the  same  minute  dose 
or  very  slightly  increasing  it.    There  are  still  at  the  present 


stimulation         fay  ^ose  wno  report  fairly  good  results  with  this  method, 

of  the  hyper-  »  1111 

susceptibility  but  further  investigation  has  proved  that  the  hypersuscepti- 
th^reby  never  bility  can  only  be  reduced  by  increasing  doses,  that  the  same 
attained  ^ose  has  no  further  effect  upon  the  hypersusceptibility  after 

tolerance.  one  or  two  inoculations.    In  fact,  experience  has  shown  that 

when  the  small  dose)  is  kept  up  for  any  length  of  time,  the 
hypersusceptibility  increases;  a  distinctly  harmful  effect  in 
such  favorable  cases  where  tuberculosis  is  quiescent  and  the 
hypersusceptibility  is  not  very  marked.  However,  this  harm 
is  very  often  overlooked  and  because  of  its  insidious  appear- 
ance, is  laid  to  the  progress  of  the  disease  and  not  to  the 
method  used  in  the  tuberculin  administration. 

A  method  The  third  method  and  most  generally  used  at  the  present 

whTie  better        day  is  the  method  which  consists  of  small  doses  increased 
ban  the  other      according  to  the  amount  of  hypersusceptibility  in  each  indi- 
remains  vidual  case.    It  is  well  known  that  to  obtain  toxic  immunity, 

weTi'chosen  we  must  begin  with  the  dose  less  than  we  require  to  produce 
cases-  toxicity,  this  dose  being  increased  in  proportion  to  the  ac- 

quired tolerance  of  the  individual.  With  that  in  view, 
methods  of  dosage  have  been  devised,  which  depend  upon  a 
mathematical  increase  of  dosage  entirely  too  rapid  or  too 
large  for  the  majority  of  patients — the  increase  in  tolerance 
not  keeping  pace  with  the  increase  in  tuberculin.  Severe 
reactions  are  frequently  encountered — thus  making  the 
choice  of  patients  for  tuberculin  treatment  absolutely  neces- 
sary. Only  long  experience  and  expert  judgment  can  bring 
about  a  fair  amount  of  accuracy  in  the  choice  of  the  pa- 
tient,— a  fact  that  stands  out  most  prominently  against  the 
wider  adoption  of  tuberculin  therapy. 

A  closer  analysis  of  the  principles  involved  in  the 
physiological  action  of  tuberculin  with  a  view  to  simplify- 
ing tuberculin  therapy,  brought  out  the  following  facts: 

FIRST:  The  dose  of  tuberculin  has  no  effect,  if  it  is 
less  than  the  maximum  amount  that  can  be  tolerated  without 
any  reaction  on  the  part  of  the  individual.  ' 


TUBERCULIN  TREATMENT  53 

SECOND:      It    requires   more    tuberculin    to    reach    the  The 

.  principles 

amount  01  maximum  tolerance  at  each  succeeding  dose.        involved 

in  the 

THIED:     The  subsequent  doses,  although  larger  than  the  physiological 
first  in  amount,  have  no  effect  if  the  first  dose  was  less  than  tuberculin, 
the  maximum  amount  that  could  be  tolerated  by  the  indi- 
vidual and  if  the  amount  of  increase  is  not  enough  to  bring 
the  total  to  the  maximum  amount  of  tolerance. 

FOURTH  :  That  any  constitutional  reaction,  however 
mild,  increases  the  amount  of  hypersusceptibility  and  the 
maximum  amount  of  tolerance  thereby  decreases,  thus  re- 
quiring a  diminution  of  the  dose  following  such  a  reaction. 

FIFTH  :  The  only  index  to  the  measure  of  tolerance  in 
every  individual  is  ;a  constitutional  reaction,  hence  a  con- 
stitutional reaction  is  desirable  in  every  case. 

SIXTH  :  Since  a  constitutional  reaction  lowers  the  point 
of  tolerance,  we  must  be  sure  to  make  such  a  reaction  as 
mild  as  possible  in  order  not  to  lower  the  tolerance  to  too 
great  a  degree. 

An  early  experience  in  otherwise  hopeless  cases  afforded 
me  the  best  opportunity  for  a  careful  elaboration  of  these 
principles  for  practical  purposes.  I  found  that  all  these  prin- 
ciples could  be  incorporated  in  a  system  of  dosage,  which  be- 
gins with  a  certain  amount  of  tuberculin,  increasing  the  dose 
subsequently  by  a  definite  amount  for  a  certain  number  of 
treatments  and  then  increasing  the  increase  at  definite  inter- 
vals until  a  reaction  is  reached.  The  reaction  thus  produced 
is  mild,  because  it  is  produced  by  the  smallest  amount  of 
tuberculin  required  to  produce  such  a  reaction  in  the  indi- 
vidual, taking  account  of  the  increased  tolerance  produced 
by  previous  injections.-  By  increasing  the  intervals,  after  The  harm 
such  reaction,  and  decreasing  the  dose  by  a  small  amount,  fromthe 

reactions 

to  offset  the  decreased  tolerance  produced  by  the  reaction,  obtained  by 
we  know  that  we  are  using  a  quantity  of  tuberculin  as  nearly  is  !ns7gnincant 
exact    for    that   particular   indivdual    as    can    be    approxi- 
mated to  produce  the  ideal  therapeutic  effect.     For  the  next 


54  TUBERCULIN  AND  VACCINE 

few  treatments,  therefore,  the  increase  need  be  but  slight 
in  order  to  keep  up'  this  full  therapeutic  effect,  and  so  this 
increase  is  begun  at  this  point  as  at  the  beginning  of  treat- 
ment, subsequently  increasing  this  increase  again,  to  make 
sure  that  we  do  not  fall  behind  in  producing  the  maximum 
effect.  A  second  reaction  may  thus  be  reached  and  even  a 
third,  during  a  course  of  tuberculin  treatment,  and  since 
these  reactions  cannot  be  but  mild,  the  continued  maximum 
effect  produced  by  thus  constantly  keeping  at  the  level  of 
maximum  tolerance,  far  outweighs  the  possible  ill  effect 
produced  by  such  mild  reactions. 

Explanation  of  Dosage  Table  I,  (Page  57.) 

If  the  treatment  requires  that  we  begin  .with  the  fifth 
Explanation  dilution  and  having  0.10  c.c.  as  the  first  dose,  the  second  dose 
would  be  0.12  c.c.,  the  third  dose  0.14  c.c.,  thus  increasing 
twice  by  0.02  c.c.  At  the  third  dose,  however,  the  increase 
should  be  increased  by  0.02  c.c.,  the  total  increase  therefore 
would  be  0.04  c.c.,  making  [the  third  tdose  0.18  c.c.  We  in- 
crease a  second  time  by  0.04  c.c,  making  the  fourth  dose  0.22 
c.c.,  again  increase  the  increase  by  0.02  c.c.  at  the  fifth  dose, 
making  the  total  increase  0.06  c.c.  and  the  fifth  dose  0.28 
c.c.  At  the  sixth  injection,  the  increase  is  the  same  as  at 
the  fifth,  making  the  quantity  of  the  sixth  injection  0.34 
c.c.,  but  at  the  seventh  injection  we  add  0.02  c.c.  again  to  the 
increase,  making  the  total  increase  now  0.08  c.c.  and  the 
quantity  for  the  seventh  injection  will  thus  be  0.42  c.c., 
repeating  the  same  increase  for  the  eighth  injection,  we 
have  as  our  eighth  dose  0.50  c.c.  This  goes  on,  increasing 
the  increase  at  every  second  treatment  by  0.02  c.c,  until  a 
full  cubic  centimeter  or  mearly  a  full  cubic  centimeter  is 
reached,  when  the  treatment  should  begin  with  a  0.10  c.c. 
of  the  fourth  dilution.  Beginning  again  with  an  increase 
of  0.02  c.c.  and  continuing  the  dosage  with  the  fourth  dilu- 
tion as  with  the  fifth  dilution,  so  also  with  the  third  dilution 
and  with  the  second,  until  the  first  dilution  is  reached. 


TUBEBCULIN  TREATMENT  55 

By  the  time  the  first  dilution  is  reached,  the  tolerance 
of  the  patient  is  usually  so  high  that  the  increase  in  the 
dosage  may  be  increased  at  every  injection,  instead  of  at 
every  other  injection.  Thus  beginning  with  ,0.10  c.c.  of 
the  first  dilution,  the  second  treatment  should  be  0.12  c.c., 
which  is  an  increase  of  0.02  c.c.  The  third  injection  should 
be  0.16  c.c.,  being  increased  by  0.04  c.c.,  the  fourth  treat- 
ment is  0.22  c.c.,  which  is  an  increase  by  0.06  c.c.  The 
fifth  treatment  is  0.30  c.c.,  making  the  increase  0.08  c.c.,  and 
so  on  until  a  full  cubic  centimeter  of  number  one  is  reached, 
making  the  conclusion  of  the  treatment  with  OT.  A  care- 
ful perusal  of  the  Table  of  Dosage,  page  57,  will  illustrate  its 
simplicity.  Should  a  constitutional  reaction  occur  after  any 
one  of  these  injections,  an  interval  of  a  full  week  is  indi- 
cated before  resuming  treatment,  commencing  then  with  the 
third  last  dose  as  illustrated  in  Table  of  Dosage  II,  page  59, 
The  treatment  is  then  continued  as  before,  but  the  amount 
of  increase  should  be  as  at  the  commencement  of  treatment, 
no  matter  what  the  quantity  of  increase  was  before  the 
reaction.  Thus,  if  a  reaction  occurs  after  0.18  c.c.  of  the 
fourth  dilution,  the  next  dose  should  be  0.12  c.c.  of  same 
dilution,  followed  by  an  increase  of  0.02  c.c.  for  two  con- 
secutive treatments,  then  by  0.04  c.c.  for  two  consecutive 
treatments  and  so  on  as  before. 

Table  of  Dosage  II  also  illustrates  the  effect  of  a  local 
reaction  on  the  subsequent  dosage — that  is,  a  local  reaction 
has  no  effect  on  the  quantity  to  be  inoculated,  but  does  require 
the  lengthening  of  the  interval  to  a  week. 

Intervals 

Tuberculin   injections   should   be  given   twice   a  week,   Tuberculin  is 

J  .  administered 

arranging    for    the    new    increase    just   before    the   longer  twice  weekly. 

of  the  two   intervals.      In  administering  two  injections   a 

week,  we  have  an  interval  of  two  days  and  another  of  three 

days,  and  since  the  increase  of  the  increase  is  made  at  every 

second  injection,  it  could  be  so  timed  as  to  fall  before  the 

three  dav  interval. 


56 


TUBERCULIN  AND  VACCINE 


A  local 

reaction  should 
lengthen  the 
interval  before 
the  next 
treatment  to 
a  full  week. 


A  focal 
reaction 
should  not 
influence  the 
course  of  the 
treatment 
except  in 
isolated 
instances. 


A  temperature 
reaction 
indicates 
a  decrease 
in  the  next 
dose,  an 
increase  in 
the  interval 
before  the 
next  dose  to 
a  full  week, 
and  the 
return  to  the 
original 
amounts  of 
increases. 


A  local  reaction  persisting  at  the  time  when  the  next 
treatment  is  due  should  indicate  a  postponement  of  the 
treatment,  lengthening  the  interval  to  a  week;  a  local  reac- 
tion still  persisting  beyond  a  week  has  no  further  signifi- 
cance. Neither  does  a  local  reaction,  when  it  is  not  accom- 
panied by  a  constitutional  reaction,  indicate  a  lessening  of 
the  dose. 

As  I  have  stated  in  another  chapter,  a  focal  reaction  is. 
merely  a  manifestation  of  the  therapeutic  and  physiological 
action  of  the  tuberculin  and  need  not  at  any  time  indicate 
either  reduction  in  dose  or  lengthening  of  interval.  How- 
ever, in  lung  cases  where  there  is  a  tendency  for  hemorrhage 
and  the  focal  reaction  brings  forth  blood  streaked  sputum,  it 
is  well  to  increase  the  interval  to  one  week  and  in  cases 
where  the  danger  of  hemorrhage  is  more  pronounced,  it  is 
best  not  to  increase  the  increase  until  this  tendency  dis- 
appears. An  increase  in  dose  by  0.02  c.c.  or  0.04  c.c.  can  be 
maintained  even  during  the  presence  of  blood  streaked 
sputum. 

The  constitutional  reaction  indicates  the  increase  of  the 
interval  to  one  week,  and  also  a  reduction  in  the  amount  of 
tuberculin — making  the  treatment  following  the  constitu- 
tional reaction  equal  to  the  third  last  dose  and  the  return 
to  the  smallest  increases  as  at  the  beginning  of  treatment. 
Should  a  constitutional  reaction  occur  after  the  first  treat- 
ment, the  interval  before  the  next  treatment  should  be  a 
week  and,  as  was  stated  elsewhere,  the  treatment  is  re- 
sumed with  one  dilution  higher.  For  example :  If  a  reac-  • 
tion  occurs  after  beginning  treatment  with  a  0.10  c.c.  of 
No.  4,  the  following  injection  should  be  0.10  c.c.  of  No.  5. 
with  treatment  from  there  on  as  if  dilution  No.  5  were  the 
first  used.  When  0.10  c.c  of  No.  5  at  the  first  injection  pro- 
duce a  constitutional  reaction,  a  sixth  dilution  must  be  made 
and  used  in  the  same  dosage  as  dilution  No.  5  would  have 
been  used. 


TUBERCULIN  TREATMENT  57 

Table  of  Dosage  I 

SHOWING  SCHEME  OF  DOSAGE  WITHOUT  REACTION 


No.  of 

Dil.              Quant 

Reaction 

Date 

Treat. 

No.             per  c.  c. 

Local         Temp. 

Jan. 

1 

1 

V*         0. 

10 

0           0 

5 

2 

0. 

12 

+0 

.02 

8 

3 

0. 

14 

+0 

.02 

12 

4 

0. 

18 

+0 

.04 

15 

5 

0. 

22 

+0 

.04 

19 

6 

-    0. 

28 

+0 

.06 

22 

7 

0. 

34 

+0 

.06 

26 

8 

0. 

42 

+0 

.08 

29 

9 

0. 

50 

+0 

.08 

Feb. 

2 

10 

0. 

60 

+0 

.10 

5 

11 

0. 

70 

+0 

.10 

9 

12 

0. 

82 

+0 

.12 

12 

13 

IV          0. 

10 

16 

14 

0. 

12 

4-0 

.02 

19 

15 

0. 

14 

+0 

.02 

23 

16 

0. 

18 

+0 

.04 

26 

17 

0. 

22 

+0 

.04 

Mar. 

1 

18 

0. 

28 

+0 

.06 

5 

19 

0. 

34 

+0 

.06 

8 

20 

0. 

42 

+0 

.08 

11 

21 

0. 

50 

+0 

.08 

15 

22 

0. 

60 

+0 

.10 

18 

23 

0. 

70 

+0 

.10 

22 

24 

0. 

82 

+0 

.12 

25 

25 

Ill           0. 

10 

29 

26 

,    o. 

12 

+0 

.02 

Apr. 

1 

27 

0. 

14 

+0 

.02 

5 

28 

0. 

18 

+0 

.04 

8 

29 

0. 

22 

+0 

.04 

12 

30 

0. 

28 

+0 

.06 

15 

31 

0. 

34 

+0 

.06 

19 

32 

0. 

42 

+0 

.08 

22 

33 

0. 

50 

+0 

.08 

58  TUBERCULIN  AND  VACCINE 


+0 . 10 
+0.10 
+0.12 

+0.02 
+0.02 
+0.04 
+0.04 
+0.06 
+0.06 
+0.08 
+0.08 
+0.10 
+0.10 
+0.12 

+0.02 
+0.04 
+0.06 
+0.08 
+0.10 
+0.12 
+0.14 
+0.16 
+0.18 


*  If  reaction  occurs  after  this  dose,  begin  treatment  with  the  sixth 
dilution.  The  dosage  of  the  sixth  dilution  being  the  same  as  the  fifth. 

f  Double  last  dose  as  a  test  for  any  possible  remaining  hypersuscepti- 
bility.  If  there  is  a  reaction  to  this  dose,  repeat  the  entire  course  of 
treatment  with  No.  1. 


26 

34 

0.60 

29 

35 

0.70 

May 

3 

36 

0.82 

6 

37    II 

0.10 

10 

38 

0.12 

13 

39 

0.14 

17 

40 

0.18 

20 

41 

0.22 

24 

42 

0.28 

27 

43 

0.34 

31 

44 

0.42 

June 

3 

45   j 

0.50 

7 

46 

0.60 

10 

47 

0.70 

14 

48 

0.82 

17 

49     I 

0.10 

21 

50 

0.12 

24 

51 

0.14 

28 

52 

0.22 

July 

1 

53 

0.30 

5 

54 

0.40 

8 

55     1 

0.52 

12 

56 

0.66 

15 

57 

0.82 

19 

58   OT 

0.10 

26 

59 

0.20f 

TUBERCULIN  TREATMENT  59 

Table  II 


SHOWING 
LOCAL 

THE  EFFECT  ON  DOSAGE  AND  INTERVALS  OF  A 
REACTION  AND  A  CONSTITUTIONAL  REACTION 

No.  of          Oil. 

Quant.                 Reaction 

Date. 

Treat.           No. 

per  c.  c.           Local 

Temp. 

Jan.      1 

1         V 

0 

.10           0 

0 

5 

2 

0 

.12 

+0.02 

8 

3 

0 

.14 

+0.02 

12 

4 

0 

.18 

+0.04 

15 

5 

0 

.22 

+0.04 

19* 

6 

0 

.28  ++  + 

0          +0.06 

26* 

7 

0 

.34       ++ 

+0.06 

Feb.      2* 

8 

0 

.42          + 

+0.08 

9 

9 

0 

.50           0 

+0.08 

12 

10 

0 

.60 

+0.10 

16 

11 

0 

.70 

+0.10 

19* 

12 

0 

.82  ++  + 

101°          +0.12 

26 

13 

0 

.60           0 

0  3d  last  dose 

Mar.     1 

14 

0 

.62 

+0.02 

5 

15 

0 

.64 

+  0.02 

8 

16 

0 

.68 

+0.04 

11 

17 

0 

.72 

+0.04 

15 

18 

0 

.78 

+0.06 

18 

19 

0 

.84 

+0.06 

22 

20 

0 

.10 

25 

21 

0 

.12 

+0.02 

29 

22 

0 

.14 

+0.02 

Apr.      1 

23 

0 

.18 

+0.04 

etc. 

etc. 

etc. 

After  each  of  the  sixth,  seventh,  and  eighth  dose  there  was  a  local 
reaction  with  a  temperature  rise  to  101°,  therefore  there  is  an  interval 
number  of  crosses  (-)-)  merely  designates  the  severity  of  the  local 
reaction:  thus  one  cross  indicates  a  mild,  two  crosses  a  moderately 
severe,  and  three  crosses  a  severe  local  reaction. 

After  the  twelfth  dose  there  was  both  a  local  and  a  constitutional 
reaction  with  a  temperature  rise  to  101,  therefore  there  is  an  interval 
of  one  week  after  the  twelfth  dose,  and  the  quantity  administered  as  a 

*  Interval  of  one  week. 


60  TUBERCULIN  AND  VACCINE 

thirteenth  dose  reduced  to  the  same  as  was  given  at  the  tenth  inocula- 
tion. The  fourteenth  dose  is  only  0.02  c.c.  larger  than  the  dose  given 
after  the  constitutional  reaction  or  dose  thirteen,  for  the  increase  after 
a  constitutional  reaction  should  be  reduced  to  the  same  quantity  .is  at 
the  beginning  of  trentincnt. 

Table  III 

BACILLARY  EMULSION  AFTER  OT 


No.  of 

Dil.                       Quant                              Reaction 

Date. 

Treat. 

No.                    per 

c.  c.                  Local          Temp. 

Aug.     5 

60 

BE  I           0. 

10               0               0 

12 

61 

0. 

20 

19 

62 

0. 

30 

26 

63 

0. 

40 

Sept.     2 

64 

0. 

50 

9 

65 

0. 

60 

16 

66 

0. 

70 

23 

67 

0. 

80 

30 

68 

0. 

90 

Oct.      7 

69 

BE  Pure      0  . 

10 

14 

70 

0. 

20 

In  cases  where  there  is  complete  clinical  cure  and  where  the 
BE  is  given  to  make  sure  that  we  obtain  a  bacillary  immunity  as  well 
as  toxic  immunity,  it  may  be  given  as  rapidly  as  indicated  in  this  chart. 


Table  IV 

BACILLARY  EMULSION  AFTER  OT.     SLOW  METHOD 

No.  of  Dil.  Quant.  Reaction 

Date.  Treat.  No.  per  c.  c.  Local  Temp. 

Aug.     5  60  BE  I  0.05  0  0 

0.10 
0.15 
0.20 
0.25 
0.30 
0.35 
0.40 
0.45 


12 

61 

19 

62 

26 

63 

Sept.  2 

64 

9 

65 

16 

66 

23 

67 

30 

68 

TUBEECULIN  TREATMENT  61 

Oct.   7     69  0.50      0      0 

14  TO  0.55 
21     71  0.60 

28  72  0.65 
Nov.  4     73   ,          0.70 

11     74  0.75 

18  75  0.80 

25  76  0.85 
Dec.  22     77  0.90 

9  78  BE  Pure  0.10 

19  79  0.12 

29  80  0.14 
Jan.   7  81  0.16 

17  82  0.18 

27  83  0.20 

Feb.   6  84  0.22 

16  85  0.24 

26  86  0.26 
Mar.  5  87  0.28 

15  88  0.30 

In  cases  where  complete  clinical  healing  has  not  taken  place  by  the 
time  OT  is  concluded  it  is  best  to  administer  BE  by  this  slow  method 
in  order  to  keep  the  patient  under  its  influence  during  treatment  for 
the  local  condition.  Open  bone  and  joint  cases  very  frequently  take 
longer  to  completely  heal  the  local  condition  than  it  takes  to  complete  a 
course  of  tuberculin.  Also  in  pulmonary  cases  with  a  cavitation,  the 
cicatrization  of  the  cavities  might  take  a  great  deal  longer  than  it 
takes  to  gain  complete  tolerance.  In  such  conditions  the  administra- 
tion of  tuberculin  should  not  be  entirely  discontinued  until  clinical 
healing  has  occurred. 

Chart  I  is  a  schematic  representation  of  the  relation  of 
tuberculin  to  a  patient's  tolerance.  A  represents  the  mini- 
mum tolerance,  a  state  where  the  patient  has  lost  the  immune 
response  and  is  absolutely  hopeless. 

C  represents  the  level  of  maximum  tolerance, — a  state 
where  the  toxic  immunity  is  complete  and  the  hypersuscepti- 
bility  has  disappeared. 


62  TUBERCULIN  AND  VACCINE 

B  represents  the  level  of  tolerance  of  a  given  tuberculous 
individual  at  the  beginning  of  tuberculin  treatment. 

Curve  X-Y  represents  a  maximum  rise  of  tolerance  with- 
out reaction  and  in  response  to  an  ideal  method  of  tuberculin 
inoculation,  were  we  in  possession  of  an  accurate  method  of 
measuring  tuberculin  to  individual  hypersusceptibility. 

(a)  is  a  curve  showing  the  influence  of  a  tuberculin 
inoculation  on  the  patient's  tolerance — when  the  first  dose 
is  too  small  to  cause  a  reaction  and  the  same  dose  is  al- 
ways repeated; — after  producing  no  result  for  a  while,  it 
would  soon  increase  the  patient's  hypersusceptibility  and 
even  lead  to  a  more  rapid  progress  of  the  disease. 

(b)  is  a  curve  showing  the  influence  of  a  course  of  tuber- 
culin inoculations  on  the  patient's  tolerance  when  the  first 
dose  is  less  than  the  patient  can  tolerate  without  a  reaction — 
the  dose  being  subsequently  increased  at  every  inoculation 
by  the  same  amount — the  increase  not  being  sufficient  to 
make  up  the  difference  between  the  preceding  dose  and  the 
amount  that  would  bring  it  to  maximum  tolerance.     The 
curve  would  rise  for  a  while,  but  would  soon  lose  in  effective- 
ness, until  the  tuberculin  would  fail  to  produce  any  results 
whatever. 

(c)  is  a  curve  showing  the  influence  of  a  course  of  tuber- 
culin inoculations  on  a  patient's  tolerance  where  the  first 
dose  is  as  it  should  be — less  than  the  patient  can  tolerate 
without  reaction — and  where  the  dose  is  increased  and  the 
amount  of  increase  also  increased.     It  thus  makes  up  for 
the  amount  of  tolerance  gained  by  each  previous  inoculation 
and  gains  upon  the  patient's  increasing  maximum  point  of 
tolerance.    Owing  to  our  inability  to  judge  when  we  are  near 
the  maximum  point  of  tolerance,  we  may  even  exceed  it  on 
several  occasions  producing  a  reaction.    This  for  the  moment 
lowers  the  patient's  tolerance.     But,  this  lost  ground  can 
easily  be  made  up,  if  with  a  proper  technique  we  avoid  too 
great  a  reaction  and  therefore  too  great  a  set-back.     Such 
a  set-back  is  advantageous,  as  it  serves  as  a  guide  to  the  most 


CJ 


<bl 


w 


TUBERCULIN  TREATMENT  63 

effective  method  of  tuberculin  therapy,  the  method  which 
keeps  the  patient  at  maximum  tolerance. 

Chart  II  is  a  schematic  representation  of  the  three 
methods  of  tuberculin  administration  and  their  effect  upon 
the  patient  and  their  comparative  success  in  removing  hyper- 
susceptibility.  As  in  Chart  I,  A  and  C  represent  the  mini- 
mum and  maximum  levels  of  tolerance  and  B  the  level  of 
tolerance  of  a  given  individual  at  the  beginning  of  tuberculin 
administration.  X-Y  represents  the  ideal  tolerance  curve  as 
in  Chart  1.  (a)  represents  a  curve  showing  the  effect  of  the 
minute  dose  method  of  administration.  This  method  has 
been  almost  abandoned,  for  it  leads  to  no  effect  at  all  or 
to  an  increased  hypersusceptibility  (lowered  tolerance), 
(b)  represents  the  effect  of  the  present-day  method  of  tuber- 
culin administration,  in  which  every  dose  is  increased  con- 
siderably, as  by  the  logarithmic  method.  In  this  method 
the  maximum  point  of  tolerance  is  soon  reached,  as  at  (f  ^ 
and  the  immunizator  not  being  aware  of  the  fact,  proceeds 
with  the  increase  which  is  equivalent  to  approximately  one- 
half  of  the  preceding  dose.  This  will  cause  quite  a  severe 
reaction  as  indicated  by  the  height  of  the  curve.  The  drop 
in  the  curve  represents  the  increased  susceptibility  together 
with  the  lowered  tolerance,  following  such  a  reaction.  The 
reduction  in  the  dose  will  soon  raise  the  tolerance  of  the 
individual  with  the  ultimate  production  of  another  reaction. 
Several  reactions  may  be  produced  during  the  treatment 
until  one  of  the  reactions  will  be  followed  by  such  heightened 
hypersusceptibility,  as  to  cause  alarm,  as  represented  at  (d). 
At  this  point,  three  different  things  may  happen  depending 
upon  the  condition  of  the  individual  and  the  attitude  of  the 
physician  administering  the  tuberculin.  The  patient  may 
possess  good  resistance,  recuperate  from  the  depression  and 
have  the  tuberculin  administrations  resumed  with  greater 
care,  and  as  represented  by  arrow  A-A,  the  patient  will  be 
brought  to  maximum  tolerance  and  a  cure  accomplished. 


64  TUBERCULIN  AND  VACCINE 

Again,  at  this  point,  (d)  the  physician  will  lose  confidence  in 
tuberculin,  abandon  its  use,  and  as  represented  at  A-B,  the 
patient's  susceptibility  will  remain  at  the  level  for  a  while, 
and  then  will  slowly  descend  with  the  progress  of  the  disease. 
As  a  third  possibility,  the  last  reaction  may  be  so  severe  that 
the  drop  of  the  curve  may  rapidly  continue  as  shown  by 
A-C,  a  rapid  progress  of  the  disease  will  ensue  and  the 
patient's  tolerance  will  be  lowered  to  the  minimum  point. 
This  is  the  method  in  vogue  at  the  present  time  and  one  can 
see  at  a  glance  how,  in  the  light  of  this  method  that  it  is  neces- 
sary for  the  physician  to  be  able  to  choose  his  patients  so 
that  they  fall  in  the  category  of  the  first  of  the  three  possi- 
bilities. And  since  the  choice  of  the  patient  requires  a 
great  deal  of  experience  and  special  training,  tuberculin 
therapy  had  to  pass  beyond  the  province  of  the  general 
practitioner. 

Curve  (c)  represents  schematically  the  method  of  tubeif- 
culin  inoculations  the  author  has  succeeded  in  working  out. 
As  in  the  other  methods,  it  begins  with  a  dose  too  small  to 
cause  a  reaction  and  less  than  the  patient's  tolerance  at  the 
moment  would  justify.  Increasing  the  dose  by  a  small 
amount  would  keep  it  just  as  far  from  the  patient's  toler- 
ance, but  this  increase  is  increased  at  every  other  inocula- 
tion, gaining  thereby  upon  the  patient's  maximum  tolerance 
until  at  point  (e)  it  approaches  the  maximum  tolerance. 
Owing  to  our  inability  to  judge  that  maximum  tolerance  is 
reached,  the  next  inoculation  is  increased  and  a  reaction  is 
produced.  But  this  reaction  is  necessarily  .a  mild  one,  as 
this  method  of  increase  allows  of  the  production  of  such  a 
reaction  as  would  be  brought  about  by  the  smallest  amount  of 
tuberculin  possible  to  produce  a  reaction  at  that  particular 
point  of  the  patient's  tolerance.  There  is  a  loss  of  tolerance 
following  such  a  reaction,  no  matter  how  mild ;  but  such  loss 
is  in  proportion  to  the  severity  of  the  reaction,  which  being 
mild,  produces  a  loss  of  tolerance  equally  mild.  From1  this 
point  on,  the  increases  are  resumed  as  at  the  beginning  of 
treatment  and  since  these  increases  are  gradually  increased 


TUBERCULIN  TREATMENT  65 

again,  another  reaction  may  be  produced  and  perhaps  sev- 
eral more  during  a  course  of  treatment,  but  in  each  case  it 
will  merely  serve  as  an  index  to  the  state  of  maximum  toler- 
ance of  the  individual.  At  no  time  are  any  of  these  reac- 
tions dangerous,  permitting  every  case  to  acquire  comp^e 
tolerance  which  is  the  goal  of  tuberculin  therapy.  It  can 
thus  be  safely  handled  by  the  general  practitioner. 

Advisability  of  Acquiring  Tuberculin  Technique 
by  First  Treating  Cases  Where  Severe  Reac- 
tions will  not  be  Dangerous. 

Xo    matter   how   simple    a    technique   may   be,    it   still  The  simPlest 

.  ..    technique  is 

requires  some  practical  experience  in  order  to  divest  it  of  susceptible 
the  uncertainties  with  which  it  seems  to  be  surrounded.  * 
Especially  is  this  true  of  a  technique  which  is  dependent 
upon  the  constitutional  effect  of  the  therapy  in  question. 
This  applies  particularly  to  tuberculin,  an  agent  which  h.is 
acquired  such  a  varied  reputation  that  one  cannot  avoid  a 
certain  amount  of  fear  and  trembling  when  first  attempting 
its  use.     The  majority  of  general  practitioners  who  awaken 
to  the  heralded  virtues  of  tuberculin  and  who  are  led  to 
begin  its  application  among  their  patients,  find  themselves 
hampered  by  two  important  drawbacks  to  its  effective  use: 
One  is  the  fact  that  they  start  out  without  any  knowledge 
of  the  mechanism  of  the  tuberculin  reaction,  nor  of  the  litera-  especially 
ture  which  is  written  upon  ;the  use  of  tuberculin.     They  do  ^a""s^,et 
not  often  delve  into  the  enormous  literature  on  the  subjtct  without  a 

•  '  p    t          i        •    t       •      i  i  conception  of 

in  order  to  get  a  fair  perspective  01  the  physiological  mechan-  the  nature  of 
ism  involved,  when  the  first  case  presents  itself  for  treat-  ^ 
ment.    They  will  commence  the  use  of  tuberculin  inspired  by 
a  single  report  in  the  Medical  Journal  where  one  or  two 
favorable  cases  may  happen  to  be  reported.     Under  such 
conditions,  it  is  no  wonder  that  the  attempt  results  in  a  hasty 
discontinuation  of  the  use  of  tuberculin.    A  poorly  measured 
quantity,  a  mistake  in  the  number  of  the  dilution,  a  failure 
even  to  wash  a  surplus  of  pure  tuberculin  from  the  syringe 
5 


66  TUBERCULIN  AND  VACCINE 

before  taking  a  quantity  of  a  weak  dilution  for  inoculation, 
will  cause  a  severe  constitutional  reaction  with  a  propor- 
tional amount  of  disaster  to  the  patient,  Kesult:  the  tuber- 
culin is  discarded  and  a  ready  recruit  is  added  to  the  ranks 
of  the  enemies  of  tuberculin.  The  prejudice  against  tuber- 
culin will  now  step  in  to  prevent  a  calm  analysis  of  the  effect 
produced  in  order  to  discover  where  the  fault  exists,  which 
really  is  with  the  technique  and  not  with  ithe  tuberculin. 

The  second  factor  .that  stands  in  the  way  of  sufficient 
it  has  been  experience  jand  fair  trial  for  tuberculin  therapy  is  the  choice 
loVse"  '  of  the  patient  when  a  physician  first  decides  to  use 

tuberculin.     Usually  he  will  try  every  conceivable  remedy 
resort  and  and  only  when  the  patient  is  hopeless  and  almost  at  death's 

'itrUlue'in7       door,  will  he  in  desperation  think  of  tuberculin  ,aiid  attempt 
general.  fa  usa    That  the  result  must  be  negative  is  inevitable.    And 

again  we  have  the  prejudice  against  tuberculin  to  help  the 
physician  attribute  ithe  loss  of  his  patient  to  the  tuberculin 
instead  of  to  his  failure  to  resort  to  it  in  time  and  to  the 
hopelessness  of  the  condition  when  first  he  attempted  its  use. 
One  can  readily  see  that  such  experiences  with  tuberculin 
do  not  only  create  adverse  judgment  in  the  mind  of  the 
physician  who  has  had  these  unfavorable  experiences,  but 
will  strengthen  the  prejudice  among  the  greater  or  lesser 
circle  in  the  community  jwhich  is  under  his  influence.  It 
is  the  aim  of  this  work  to  lay  before  the  medical  profes- 
sion in  as  simple  terms  as  possible  the  details  of  tubercu- 
lin therapy;  but  however  simplified  and  simply  expressed 
they  may  be,  details  they  still  are,  and  as  such  require 
attention.  Yet  it  would  be  demanding  the  impossible  to 
expect  the  beginner  with  a  new  technique  to  be  perfect  in 
every  detail.  But  since  in  tuberculin  therapy  the  oversight 
of  such  details  may  cause  unpleasant  symptoms  and  dan- 
gerous effects  in  the  patients,  and  since  such  accidents  can- 
not be  avoided,  it  is  advisable  to  choose  tubercular  conditions 
where  such  mistakes  will  do  the  least  damage. 

Such  tubercular  conditions  are  found  among  the  cervical 
adenitis  and  lupus  cases.     The  fact  that  the  process  is  lim- 


TUBERCULIN  TREATMENT  67 

ited  to  the  glandular  system  in  the  former,  shows  the  great  Tubercuiar 

cervical 

amount  of  resistance  the  patient  possesses  to  tuberculosis,   adenitis  and 
The  patient  is  usually  in  robust  health  with  no  other  dis-  5"^,*™ 
comfort  except  the  enlarged  glands.     The  severest  constitu-  conditions 
tional  reaction  possible  can  consist  of  bodily  discomfort  last-  trial  with 
ing  a  day  or  two.    Then  recovery  goes  on  even  more  rapidly  tuberculin 
at  times  after  such  an  experiment;   and  if  with  a  little 
care  the  exact  cause  of  such,  a  reaction  is  determined,  over- 
looked  details   will   receive   due   attention   in   the   future. 
In  this  way  each  factor  in  the  proper  technique  will  become 
impressed  upon  the  mind  so  that  by  the  time  the  physician 
concludes  the  treatment  of  one  single  case,  he  shall  have 
acquired  almost  a  complete  mastery  over  this  technique. 


CHAPTER  III 
TUBERCULOSIS  OF  THE  GLANDS 

Our  present  knowledge  of  the  process  of  infection  by  the 
tubercle  bacillus  leads  us  to  the  conclusion  that  the  tuber- 
culosis of  glands  represents  the  primary  form  of  tubercular 
infections.     The  most  recent  investigations   regarding  the 
entrance  of  the  tubercle  bacillus  into  the  organism,  and  its 
future  role  as  forming  the  various  processes  of  tubercular 
infections,    leads   to   the   plausible   conclusion    that    tuber- 
culosis,   like    syphilis,    has    three    stages.      The    infection 
of  glands  represents  the  first  stage,   and  therefore  comes 
Tuberculosis,       mainly  in  .early  childhood ;  the  infection  of  bones  and  joints 
maybTcon-5        represents  the  second  stage  and  the  infection  of  the  lungs 
sideredin  represents   the   third  stage  of  the  disease.     It  is  not   the 

three  stages:  ..  .  -iii-n 

the  glandular       point  in  question  here  whether  the  tubercle  bacillus  enters 
b'onc'&nd  *^e  peri-bronchial  ,or  mediastinal  glands  by  way  of  the  bron- 

joint  stage,  chioles ;  or,  whether  the  mesenteric  glands  are  infected  by 
pulmonary  way  of  the  bowel  walls ;  or,  whether  the  glands  of  the  neck 
p*gse>  i  &  x  are  infected  through  the  tonsils ;  or,  whether  the  bacillus  gains 
entrance  through  inhalation  or  infected  food.  What  is  of 
interest  to  us  from  a  practical  point  of  view,  is  that  infants 
rarely  die  of  tuberculosis  of  the  lungs  as  a  primary  infec- 
tion; that  as  a  general  rule,  the  infections  of  bones  and 
joints  occur  in  children  older  than  those  affected  with 
glands  and  younger  than  those  suffering  from  infection  of 
the  lungs;  and  that  nearly  all  glandular  enlargements  in 
individuals  dying  from  causes  other  than  tuberculosis  were 
found  to  ,be  tuberculous.  These  facts,  together  with  the 
large  mass  of  research  in  tubercular  infections  throughout 
the  world  seem  to  leave  no  room  for  doubt  that  such  three 
stages  of  the  infection  exist  and  that  tuberculosis  of  the 
glands  is  the  primary  form  of  the  infection.  We  see  case 
after  case  of  tuberculosis  of  the  glands  of  the  neck  followed 
by  tuberculosis  of  the  bone  and  if  double  infection  occurs  in 


FIG.  13. — ILLUSTRATES  THE  THREE  STAGES  IN  ONE  INDIVIDUAL,  GLANDS; 

BONE  (sternoclavicular  joint  and  sternum)  ;  LUNGS. 
This  patient,  a  Chinaman,  twenty-five  years  old,  has  had  suppuration 
of  the  glands  of  the  neck  since  early  childhood.  Several  operations, 
two  of  them  radical,  were  performed,  but  each  time  the  wound  failed  to 
close.  About  two  years  ago,  and  directly  after  the  last  operation,  the 
disease  extended  to  the  sternoclavicular  joints  on  both  sides.  A  cough 
developed  which  lasted  for  two  years.  On  examination,  both  lungs  were 
very  extensively  involved.  He  disappeared  from  the  clinic  after  a  few 
visits.  We  subsequently  learned  that  he  was  discouraged  from  taking 
tuberculin  treatment  by  other  physicians  (as  if  there  was  any  chance 
for  recovery  by  any  other  treatment). 


FIG.  14. — ILLUSTRATES  THE  THREE  STAGES  IN  A  CHILD,  GLANDS   (neck 

and  mediastinal) ;  BONES  (both  hips) ;  PULMONARY. 
This   photograph   represents   a   niore   rapid   progress   of   the   disease, 
where  little  natural  resistance  could  be  developed  during  the   spread 
from  one  stage  of  the  disease  to  the  other. 


TUBERCULOSIS  OF  THE  GLANDS  69 

a  very  young  child,  it  finally  dies  of  an  extension  into  the 
lungs.  In  older  individuals,  the  process  will  remain  in  the 
bone  or  joint,  the  glands  perhaps  showing  a  tendency  to 
heal.  The  process  then  becomes  very  chronic,  the  resistance 
of  the  patient  being  sufficient  to  prevent  an  extension  into 
the  lungs,  but  not  quite  sufficient  to  put  an  end  to  the 
infection. 

It  therefore  follows,  that  since  tuberculosis  of  the  glands 
represents  the  primary  lesion,  it  offers  an  ideal  situation  for 
the  checking  of  the  infection,  and  this  should  be  pur  'main 
aim.  The  removal  of  the  hypersusceptibility  by  a  course  of 
tuberculin  will  remove  the  probability  of  an  extension  of  the 
disease. 

The  healing  of  the  local  lesion  is  by  far  less  important.   Since  the 

.    .          .        glandular 

Too  much  attention  has  been  paid  to  the  local  condition  in  form  of  the 

glandular  tuberculosis  and  the  efficacy  of  tuberculin  treat-  ^rellnts 

ment  in  tubercular  glands  was  judged  by  ;the  course  of  the  the  primary 

local  process  during  the  treatment.     The  success  of  tuber-  offers  the 

culin  thus  depended  upon  the  presence  or  absence  of  co-  'deal  SItuatlon 

for  immuno- 

existing  processes  other  than  the  tubercular  affection;  for  therapy. 
we  know  that  many  processes  can  supervene  upon  a  tuber- 
cular process  which  may  remain  after  successful  treatment  Weare 
was  directed  against  the  tubercular  process  alone.    If,  on  the  a  constitutional 
other  hand,  we  remember  the  greater  responsibilitv,  —  that  of  ,dlsef  se>  lts 

••'  '  local  mam- 

checking  an  infection  which  is  in  its  primary  stage,  —  and  festations 
give  our  attention  to  the  local  condition  secondarily,  the  great  on°y  secondary 
utility  of  tuberculin  in  tubercular  infections  would  becom'j  consideration. 
apparent  to  every  one. 

The  radical  surgical  operation  is  a  severe  incursion  upon  The  radicai 
the  alreadv  delicately  balanced  organism  and  the  recurrence  °Perationis 

J  a  failure  for 

is  due  to  the  tubercle  bacillus  left  behind,  not  on  account  of  the  reason 
the  lack  of  surgical  skill,  but  because  of  the  presence  of  the  wiVthe^ocai 
tubercle  bacilli  which  are  beyond  the  reach  of  the  knife,  conditions 

alone,  and 

The  organism  thus  rendered  more  susceptible  allows  of  a  may  do  great 
greater  spread   of  the  disease  than   before   the  operation,  r^™in^  the 


for  the  hypersusceptibilitv  is  greatly  increased  by  any  surg-  natural 

Jr  "  .  resistance  of 

ical  interference  requiring  a  general  anesthesia.  the  patient. 


70 


TUBERCULIN  AND  VACCINE 


Closed 
tubercular 
glands  con- 
sist of  two 
varieties, 
the  hyperplastic 
glands  which 
undergo 
caseation  and 
softening 


and 


the  fibrous 
glands  with 
scar  tissue 
formation. 


Classification.  A  more  detailed  classification  with  regard 
to  the  pathological  processes  involved  in  tubercular  glands 
will  greatly  simplify  the  whole  matter  and  will  render  much 
clearer  the  differentiation  between  the  tubercular  process 
and  other  pathological  processes  that  may  supervene.  Once 
such  differentiation  is  made,  we  shall  know  on  the  one 
hand  what  to  expect  of  the  tuberculin  and!  we  shall  recog- 
nize, on  the  other  hand,  the  necessity  for  other  therapeutic 
measures  when  they  are  indicated. 

Closed  Glands 

Under  this  heading,  we  class  all  tubercular  glands  that 
are  enlarged,  but  have  not  broken  down.  They  remain 
as  masses  of  various  sizes  with  a  process  that  is  purely 
tubercular.  Consequently,  we  have  two  varieties  of  closed 
glands  each  dependent  upon  one  of  the  other  of  the  two 
varieties  of  processes  that  tuberculosis  gives  rise  to ;  that  is, 
hyperplastic  and  fibrous.  To  [the  hyperplastic  variety  belong 
the  glands  where  the  glandular  substance  increases  together 
with  infiltration  of  the  stroma,  causing  poor  blood  supply 
to  the  center  of  the  gland.  The  center  of  the  gland  soon 
liquefies  and  finally  forms  a  cold  abscess,  or  soft  gland.  It 
may  remain  soft  for  a  Jong  time.  If  left  alone,  the  soft 
gland  will  finally  acquire  a  tryptic  ferment  which  will  digest 
its  capsule,  finally  eating  its  way  out  to  the  surface  and  pro- 
duce very  ugly  scarring.  This  process  resembles  a  sloughing 
process.  It  is  therefore  necessary  at  the  outset  to  aspirate 
these  glands  and  treat  them  as  described  in  Part  III,  under 
"  Surgical  Treatment." 

The  fibrous  glands  are  those  in  which  the  individual  has 
a  fair  amount  of  resistance  and  reacts  to  the  tubercular  pro- 
cess by  fibrous  tissue  degeneration.  The  longer  the  process 
goes  on,  the  denser  becomes  the  fibrous  tissue  in  these  glands 
so  that  when  a  course  of  tuberculin  has  checked  the  tuber- 
cular infection,  this  fibrous  tissue  will  contract  to  a  greater 
or  lesser  extent  as  a  result  of  complete  healing.  Since  fibrous 


FIG.  15. — ILLUSTRATES  THE  FIRST  AND  SECOND  STAGE — GLANDS  OF  THE 

NECK  AND  BONE. 

This  patient,  fifty-four  years  of  age,  has  been  suffering  from  the 
glandular  and  bone  infection  for  fifty-one  years.  The  spread  from  the 
glands  in  the  neck  to  the  bones  and  joints  was  very  rapid,  but  here  the 
progress  remained  very  slow  and  although  the  disease  spread  from  one 
joint  to  another,  there  was  sufficient  resistance  to  prevent  the  spread 
into  the  Ulna's. 


TUBERCULOSIS  OF  THE  GLANDS  71 

tissue  does  not  entirely  absorb,  it  will  very  frequently  leave 
a  hard  nodule,  the  size  of  which  depends  upon  the  number 
of  glands  involved.  (Fig.  16.) 

One  can  readily  see  the  fallacy  in  the  conclusion  that 
tuberculin  has  not  cured  the  patient  if  such  a  nodule  persists 
But  a  slight  experience  is  needed  with  the  radical  operation 
for  the  removal  of  these  glands  to  appreciate  the  difference 
between  an  operation  such  as  would  be  required  before  tuber- 
culin had  been  administered  and  one  that  would  be  sufficient 
to  merely  remove  the  cicatrized  glands  after  tuberculin  had 
been  administered.  ,(Fig.  17.) 

Open  Glands. 

By  open  glands  we  mean  glands  that  suppurated  to  the  open  glands 
surface.     They  are  of  two  distinct  varieties.     Those  that  varieties" 
have   broken   down    as    a   result    of   tryptic   ferments,    the  <a)  those 

ft  c        i  •    i      •  -i  111  i  11  broken  down 

discharge  of  which  is  sterile;  and  those  tthat  have  broken  by  tryptic 


down  through  suppuration  due  ;to  a  mixed  infection.     Of 
the  latter,  there  are  two  varieties:  the  suppurating  hyper-  broken  down 
plastic  variety  (Figs.  6  (and  7)  and  the  suppurating  fibrous  infection. 
variety.      In   the   process    of   healing   during   a   course   of 
tuberculin,    no    difficulties   will    be  [met   with  in   the  case 
of  any  of  the  open  glands,  except  with   the  fibrous  sup- 
purating variety.     While  it  may  happen  that  the  mixed  of  the  second, 
infection  goes  on  to  destroy  all  of  the  fibrous  tissue,  this  is  t(wo'  ^""4",: 
not  usually  the  case.     A  large  amount  of  fibrous  tissue  will  (O  suppurating 
remain  after  both  the  tubercular  and  the  mixed  infection  (2)  suppurating 
have  been  checked,  so  that  here  again  we  have  a  case  where  fibrous- 
surgical    interference    may   be   necessary   to   complete    "  a 
cure."     (See  Part  III.) 

Recurrent  G-lands  After  Radical  Operation. 

(Figs.  8  and  9.) 

A   recurrence   after  radical   operation  may   take   place  Postoperative 
immediately  after  the  operation,  preventing  primary  heal-  r^^reot 
ing  of  the  incision;   the  sutures  break  apart  and  a  large  two  varieties: 


72 


TUBERCULIN  AND  VACCINE 


(a)  Those 
recurring 
immediately 
after  operation 
consisting 
mainly  of 
mixed 
infection; 


(b)  Those 
coming  on 
slowly  and 
some  time 
after  the 
operation. 


Three-grades 
of  hypersus- 
ceptibility 
exist  in 
tubercular      . 
adentitis. 


suppurating  area  forms,  with  a  mass  of  enlarged  glands 
beneath  it.  The  rapidity  with  which  the  glands  enlarge, 
from  an  ,invisible  size  to  a  mass  almost  as  large  as  previous 
to  'the  operation,  implies  mixed  infection,  for  the  tubercu- 
lar process  alone  can  not  cause  such  rapid  enlargement, 
However,  the  increased  hypersusceptibility  is  a  factor  in  the 
recurrence.  .These  patients  will  very  often  run  high  tem- 
peratures and  show  marked  symptoms  of  toxemia.  The 
treatment  of  the  mixed  infection  as  described  in  Part  III 
of  this  work,  must  be  persisted  in  until  the  temperature  is 
reduced  before  tuberculin  inoculations  are  begun. 

Another  form  consists  of  a  recurrence  some  time  after 
a  seemingly  successful  operation.  These  glands,  as  a  rule, 
come  on  more  slowly,  are  of  a  purely  tubercular  character 
and  should  be  treated  as  .closed  glands,  taking  into  account 
the  heightened  susceptibility.  This  increased  hypersuscep- 
tibility may  persist  no  matter  how  long  an  interval  has 
elapsed  between  the  operation  and  the  tuberculin  treatment. 
Glands  enlarged  through  a  tubercular  process  on  the  opposite 
side  of  the  neck  or  anywhere  else  -in  the  body  should  be 
treated  the  same  as  recurrent  glands,  if  they  appear  after 
a  radical  operation;  that  is,  we  must  take  into  account  the 
heightened  susceptibility  due  to  the  operation,  no  matter 
whether  the  process  is  recurrent  or  newly  formed.  (Fig.  20.) 

General  Hypersusceptibility 

We  have  three  distinct  grades  of  general  hypersuscepti- 
bility to  deal  with  in  tubercular  lynrphomata.  The  closed 
glands  represent  the  Jowest  grade  of  hypersusceptibility. 
That  is  easily  .explained  when  we  recall  that  the  glands  in 
the  body  are  the  filters  and  detain  the  infectious  organisms 
on  their  way  to  the  more  vital  organs.  That  is  also  the 
reason  why  glandular  tuberculosis  represents  the  primary 
infection  with  the  tubercle  bacillus.  It  therefore  follows 
that  so  long  as  the  glands  remain  closed,  they  are  success- 
fully coping  with  the  infectious  organisms,  although  they 
are  undergoing  pathological  changes  as  a  result.  As  soon 


TUBERCULOSIS  OF  THE  GLANDS  73 

as  these  glands  break  down,  they  no  longer  serve  as  filters, 
extension  of  the  process  becomes  more  likely  and  thus  repre- 
sents a  heightened  susceptibility.  The  third  grade  of  hyper- 
susceptibility  occurs  in  glands  that  appear  as  an  active  pro- 
cess in  spite  of  and  following  .a  radical  operation. 

There  is  one  exception  to  the  general  rule  of  hypersus- 
ceptibility in  tubercular  glands,  and  that  is:  after  an  infec- 
tious  disease  the  jhypersuseeptibility  is  very  high  in  any 
form  of  tubercular  glands,  even  in  case  of  the  closed  form,   increase  the 
This  increase  in  hypersusceptibility  bears  no  relation  to  the 


severity  of  the  infectious  disease,  as  !we  may  have  a  much  to  a  marked 
larger  increase  in  hypersusceptibility  after  a  mild  attack 
of  grippe  or  varicella  than  iafter  a  severe  scarlet  fever. 
However,  we  must  remember  that  an  increase  in  hypersus- 
ceptibility does  occur  and  must  be  taken  account  of  if  tuber- 
culin treatment  is  resorted  to  before  six  months  have  elapsed. 
We  have  all  noticed  the  frequency  with  which  tubercular  pro- 
cesses in  children  first  make  their  appearance  after  a  conta- 
gious disease.  That  is  most  likely  due  to  heightened  sus- 
ceptibility as  a  result  of  the  infectious  disease,  rendering  a 
quiescent  lesion  active.  (See  Temperature  Charts,  page 
151,  152.) 

Beginning  Treatment. 

From  the  above,  it  follows  that  in  the  treatment  of  The  beginning 
closed  tubercular  glands,  0.0001  c.c.  of  tuberculin  or  0.10  t°ber°uiin. 
c.c.  of  the  third  dilution  would  not  be  too  large  a  begin- 
ning dose.  In  the  open  tubercular  glands,  0.00001  c.c. 
or  0.10  c.c.  of  the  fourth  dilution  would  be  less  likely 
to  give  a  reaction  from  the  first  dose.  In  cases  follow- 
ing a  radical  operation,  0.000001  c.c  of  tuberculin  or  0.10 
c.c  of  the  fifth  dilution  should  be  the  beginning  dose  if  the 
recurrence  appears  immediately  after  the  operation.  If  the 
recurrence  does  not  appear  until  some  time  after  the 
operation  and  the  patient  seems  in  good  physical  condition, 
0.00001  c.c.  or  0.10  c.c  of  the  fourth  dilution  should  be  the 
beginning  dose.  The  same  holds  true  in  tubercular  glands 


74  TUBERCULIN  AND  VACCINE 

if  the  treatment  is  begun  before  the  elapse  of  six  months 
after  contagious  disease,  when  0.000001  c.c.  or  0.10  c.c.  of 
the  fifth  dilution  is  a,  safe  dose  to  begin  with.  Occasionally 
the  hypersusceptibility  is  so  marked  as  evidenced  by  a  daily 
temperature  rise  and  by  a  marked  irritability  of  the  patient, 
that  the  sixth  dilution  should  be  made  and  the  treatment  be- 
gun with  a  0.10  c.c.  making  the  beginning  dose  0.0000001  c.c. 
of  tuberculin.  In  the  treatment  of  Orientals  or  negroes,  one- 
tenth  the  quantity  advised  as  beginning  treatment  above 
should  be  the  beginning  dose  under  similar  conditions. 

Conclusion  of  Treatment. 

The  conclusion  In  glandular  tuberculosis,  it  is  rarely  necessary  to  con- 

clude the  tuberculin  treatment  in  any  way  other  than  is 
shown  on  ,the  general  scheme  of  dosage,  as  described  in  the 
last  chapter.  After  the  administration  of  the  BE  the  patient 
returns  every  three  months  for  test  inoculation  to  determine 
whether  there  is  a  tendency  for  the  return  pf  hypersuscepti- 
bility.  The  method  of  testing  will  be  described  more  fully 
under  its  own  heading.  (See  page  147.) 

Results. 

The  results  The  results  obtained  from  the  treatment  of  tubercular 

have  been  glands  with  tuberculin  leave  no  'doubt  that  tuberculin  is  the 

treatment  par  excellence  for  this  condition.     Among  others 

good  where  * 

tuberculin  the  late  Doctor  John  B.  Murphy,  of  Chicago,  found  that  in 

adopted.  a  number  of  years  no  case  of  glands  of  rthe  neck  required 

operation  where  a  course  of  tuberculin  had  first  been  given. 
That  the  radical  operation  is  contra-indicated  in  every 
case  of  tubercular  glands  is  beyond  dispute.  Those  that 
still  resort  to  the  radical  operation  will  find  the  responsibility 
harder  to  shoulder  with  the  ever  increasing  recognition  of 
the  fact  that  glands  can  be  cured  without  it.  There  are  those 
who  deny  that  tuberculin  will  cure  all  cases  of  glands.  This 
denial  may  be  based  upon  the  expectation  that  tuberculin 
should  not  only  cure  the  infection,  but  must  eradicate  every 


TUBERCULOSIS  OF  THE  GLANDS  75 

sign  of  the  disease.     Many  have  "  tried  "  tuberculin  and  The  radical 
have  discontinued  every  other  treatment.    And  when  tuber-  ^beroTiar  °r 
culin  failed  to  remove  a  mixed  infection,  or  when  tuber-  *landsis 

'  contra-indicated 

culm  eradicated  the  tubercular  infection  but  left  behind  a  under  an 
mass  of  fibrous  tissues  which  could  not  be  absorbed,  these 


masses  were  pointed  out  las  the  original  glands  and  it  was  if  u  does  not 

declared  that  tuberculin  had  failed  in  its  therapeutic  effects,  traces  of 

Granting  that  a  surgeon  honestly  believes  that  glands  en-  atTetstTi'mit 

larged  through  tuberculosis  ought  to  be  removed,  —  he  ought  surgical 

,  ,  .  j'lj-i  i  i       •      •       interference 

even  then  to  take  cognizance  01  the  tact  that  tuberculosis  is  to  the 
a  systemic  disease  and  ought  in  every  case  rid  the  system  of  removal  of 

•*  •>  a  cicatrized 

the  hypersusceptibllity  before  resorting  to  surgery  for  the  mass  which 
local  condition.     If  this  fact  were  always  considered,  the  absorbed. 
whole  problem  would  automatically  adjust  itself  to  all  forms 
of  opinion.    For,  the  surgeon  would  observe  the  large  number 
of  patients  who  get  well  without  operation.    He  would  also 
notice  that  when  an  operation  is  performed  after  tuberculin, 
the  fact  that  no  recurrence  takes  place  would  more  than 
emphasize  the  advisability  of  a  course  of  tuberculin  before 
operation. 

In  hospital,  as  well  as  in  private  practice,  I  have  had  uni- 
formly good  results  iwith  tuberculin  in  the  treatment  of 
glandular  tuberculosis.  In  only  /two  cases  was  an  operation 
necessary  and  both  these  cases  were  post-operative  recurrent 
glands.  One  patient  (Fig.  17)  had  had  a  radical  operation  for 
cervical  adenitis,  with  recurrence  in  the  submaxillary  region. 
Applying  for  treatment  about  four  months  after  the  radical 
operation,  we  found  the  incision  for  the  radical  operation 
extended  from  the  tip  of  the  mastoid  to  two  inches  above  the 
clavicle,  then  at  right  angles  across  the  neck  to  the  sterno- 
clavicular  joint.  The  lower  half  of  the  horizontal  incision 
was  suppurating  and  consisted  of  a  large  granulating  sur- 
face. She  also  presented  a  very  high  grade  of  hypersuscepti- 
bility  with  a  mass  in  the  submaxillary  region  the  size  of  a 
hen's  egg  on  the  same  side  where  the  operation  was  per- 
formed. This  mass,  during  treatment,  reduced  to  the  size 
of  a  walnut,  but  persisted  after  the  conclusion  of  the  course 


76  TUBERCULIN  AND  VACCINE 

of  tuberculin.  Under  local  cocain  anesthesia  and  through 
a  half-inch  incision,  the  mass  was  removed,  the  incision  clos- 
ing by  primary  union,  leaving  an  almost  invisible  scar.  The 
removed  mass  consisted  of  a  very  dense  fibrous  tissue  with 
hardly  a  vestige  of  glandular  substance  to  be  seen.  During 
the  tuberculin  treatment,  the  patient  gained  twenty  pounds 
in  weight,  and  lost  the  nervous  irritability  and  tremor  of 
the  hands  which  she  had  when  she  first  presented  herself 
for  treatment. 

The  second  case,  a  woman  twenty-nine  years  of  age,  with 
a  negative  family  history,  was  always  well  before  the  present 
complaint  and  did  not  remember  any  diseases  of  childhood. 

At  the  age  of  fifteen,  the  glands  of  the  neck  on  both  sides 
began  to  swell;  and  until  six  years  ago,  the  swelling  con- 
tinued, sometimes  in  a  milder  form,  sometimes  very  marked, 
at  times  almost  disappearing  on  one  side  and  then  on  the 
other,  but  iat  no  time  was  she  free  from  enlargement  of  the 
glands  of  the  neck. 

Six  years  ago  she  suddenly  developed  a  painful  enlarge- 
ment of  her  whole  abdomen,  the  pain  being  specially  marked 
in  walking  and  from  any  jar  whatsoever.  About  a  month 
later,  an  exploratory  laparotomy  was  performed  and  exten- 
sive tubercular  peritonitis  was  discovered.  Thirty  ounces  of 
fluid  were  removed  and  the  peritoneal  cavity  exposed  to  the 
air  and  sunlight  for  "  one  hour."  Xine  days  after  this 
operation  the  abdominal  cavity  refilled,  and  after  remaining 
confined  to  her  bed  for  six  weeks  she  was  sent  to  a  sanitarium 
in  the  mountains  where  she  improved,  the  fluid  disappearing 
from  the  abdomen  after  a  period  of  six  months. 

One  year  later,  the  glands  of  the  neck,  which  were  of  the 
closed  variety  up  to  the  present  time,  began  t/>  suppurate, 
especially  the  sublingual  mass.  Under  a  general  anesthesia 
and  through  an  incision  extending  from  the  angle  of  the 
lower  jaw  on  one  side  to  the  same  point  on  the  other  side 
a  complete  removal  of  this  mass  of  suppurating  glands  was 
thought  to  have  been  carried  out,  but  soon  after  the  opera- 
tion the  mass  recurred,  and  the  incision  suppurated  at  several 


TUBERCULOSIS  OF  THE  GLANDS  77 

points.  A  month  or  two  later,  another  radical  procedure  was 
carried  out  over  a  suppurating  supraclavicular  mass  on  the 
right  side,  with  no  better  result;  and  during  the  year  fol- 
lowing, six  more  general  anesthesias  were  administered  to 
the  patient  for  the  removal  of  one  mass  after  another  in  both 
the  cervical  regions  on  both  sides  of  the  neck  the  supra- 
clavicular  region  on  the  left  side,  and  in  the  suprasternal 
region.  The  posterior  cervical  chains  suppurated  on  both 
sides  but  no  attempt  for  their  removal  was  made.  Soon  after 
the  last  operation  on  the  neck,  and  two  years  after  the  first 
abdominal  operation,  the  upper  right  abdomen  began  to  swell 
and  in  the  course  of  the  following  few  weeks  two  large  abdo- 
minal abscesses  were  opened  and  drained.  These  abscesses 
did  not  penetrate  into  the  abdominal  cavity  and  healed  in  a 
few  weeks.  About  eight  months  later,  an  acute  swelling  of 
the  abdomen  again  occurred  with  symptoms  of  peritonitis, 
such  as  abdominal  rigidity,  nausea  and  vomiting.  Laparo- 
tomy  was  performed  through  the  former  median  incision.  A 
suppurating  appendix  was  removed  and  a  number  of  tuber- 
cular masses  were  found  and  removed.  The  patient  recovered 
from  this  operation,  but  suppuration  of  the  incision  occurred 
with  the  formation  of  a  fecal  fistula.  Soon  after  this  opera- 
tion, a  large  mass  of  glands  in  the  right  axilla  developed 
which  suppurated  a  few  months  later.  The  patient  applied 
for  tuberculin  treatment  several  months  after  the  last  abdo- 
minal operation  (March  30,  1914).  She  weighed  130  pounds 
although  she  is  five  feet  eight  inches  tall,  was  very  pale,  and 
highly  neurotic.  Around  the  neck,  including  both  supra- 
clavicular  and  suprasternal  regions,  the  anterior  and  poste- 
rior cervical  and  the  sublingual  regions  were  studded  with 
openings  from  suppurating  glands  (about  fifteen  in  all)r 
oozing  a  thick  creamy  pus.  The  lower  jaw  gave  the  ap- 
pearance of  acromegaly  from  the  Distortion  brought  about 
by  the  enlargement  of  the  submaxillary  and  sublingual 
glands.  The  abdominal  wall  showed  two  longitudinal  scars 
in  the  upper  left  quadrant  and  a  median  scar  running  from 
the  umbilicus  to  the  symphasis  pubic.  In  the  lower  part  of 


78  TUBERCULIN  AND  VACCINE 

the  median  scar  and  about  one-half  inch  above  the  symphasis 
there  was  a  fistulous  opening  from  which  oozed  a  thick 
creamy  pus,  and  after  physic  had  been  taken  this  would  dis- 
charge feces.  The  tuberculin  treatment  continued  uninter- 
ruptedly until  April  i9,  1915,  and  except  for  a  few  mild  con- 
stitutional reactions  and  a  number  of  severe  local  reactions 
the  patient  improved  steadily,  weighing  180  pounds  at  this 
time.  Five  masses  persisted  beyond  this  treatment,  three  on 
the  left  side  and  two  on  the  right  side  of  the  neck.  The  two 
masses  on  the  right  side  were  removed  under  cocain  anes- 
thesia with  primary  union.  In  August,  1916,  I  performed 
an  operation  for  the  relief  of  the  fecal  fistula,  and  at  the 
same  time  removed  one  more  mass  on  the  left  side  of  the  neck. 
Outside  of  tuberculin,  a  vaccine  for  mixed  infection  was 
administered  during  her  treatment,  and  just  before  the 
operation  for  the  removal  of  the  fecal  fistula,  three  prophy- 
lactic inoculations  of  strepto-fecalis  and  colon  bacillus  were 
administered  a  week  apart: 

First  dose  strepto-fecalis  250  mil.    Colon  bacillus  250  mil. 
Second  dose  strepto-fecalis  500  mil.     Colon  bacillus  500 
mil. 

Third  dose  strepto-fecalis  1000  mil.     Colon  bacillus  1000 
mil. 

The  important  points  to  be  noted  in  this  case  are : 

1.  The  rapid  extension  of  the  tubercular  process  to  all  the 
glands  of  the  neck  and  their  final  breaking  down  did  not 
take  place  until  after  a  major  surgical  operation  (laparo- 
tomy)  was  performed  although  the  glands  were  diseased 
for  many  years  before. 

2.  The  tubercular  affection  of  the  glands  is  only  a  local 
manifestation  of  a  constitutional  disease.    The  attempted 
extensive  operation  for  the  relief  of  the  local  process  only 
lowered  the  resistance  of  the  patient,  allowing  the  dis- 
ease to  get  a  firmer  hold  on  the  constitution,  which  mani- 
fested itself  at  some  point  of  lessened  resistance — most 
often  at  the  point  of  operation  and  sometimes  in  more 


TUBERCULOSIS  OF  THE  GLANDS  79 

vital  organs  which  happened  to  be  in  a  state  of  lowered 
resistance. 

3.  Masses  of  fibrous  tissue  may  become  foreign  tumors  after 
the  infection   (disease)   has  been  eradicated,  and  may 
require  removal. 

4.  The  removal  of  these  masses  is  infinitely  simpler  and 
safer  after  the  constitutional  disease  has  been  overcome. 

5.  Although  at  the  first  two  laparotomies,  extensive  tuber- 
cular peritonitis  was  found,  there  was  no  sign  of  peri- 
toneal involvement  found  at  the  laparotomy  for  the  cure 
of  the  fecal  fistula  performed  after  the  tuberculin  treat- 
ment. 

6.  Prophylactic   immunization  with  stock  vaccine  of  bac- 
teria found  by  a  bacteriological  examination  of  the  fistu- 
lous  discharge  made  a  cure  by  one  operation  possible. 
(See  Part  III.) 

In  both  these  above  cases  it  will  be  seen  jhow  much  more 
effective  surgery  is  when  applied  in  a  condition  that  is 
purely  local  than  in  a  similar  condition  when  the  local  mani-  Tuberculin 
festation  is  still  a  manifestation  of  a  systemic  condition,   iniooper* 
With  Petruschky  and  Kramer,  I  hold  that  tuberculin  will  «"*<>*  «* 

J  of  adenitis. 

effect  a  cure  in  100  per  cent,  of  cases.  From  extensive 
experience  in  recurrent  cases  after  radical  operation,  I 
maintain  that  the  radical  operation  cannot  be  justified  in 
any  case;  and  in  a  child  under  five  years  of  age,  it  is 
criminal ;  for,  in  those  cases  a  resistance  has  not  been  built 
up  to  any  degree  and  a  general  dissemination  is  very  immi- 
nent. The  following  is  a  case  to  illustrate  this  point. 

Willie  K.,  born  in  September,  1913,  whose  family  history 
was  negative,  had  a  normal  birth  and  was  Always  well.  On 
September  1,  1914,  a  swelling  was  noticed  on  the  left  side  of 
his  neck.  This  grew  larger  until  November  20th,  when  a 
radical  operation  for  the  removal  of  tubercular  glands  was 
resorted  to,  the  incision  extending  for  three  inches  along  the 
inner  border  of  the  sternocleidomastoid  muscle.  The  wound 
reopened  soon  after  the  operation,  forming  a  granulating  sur- 


80  TUBERCULIN  AND  VACCINE 

face  occupying  nearly  the  entire  side  of  the  neck.  When  the 
child  was  brought  under  ray  care  on  February  10,  1915,  his 
temperature  ranged  for  a  week  previous  between  101°  F.  and 
105°  F.  daily,  the  wound  in  the  neck  consisted  of  an  oval 
depression  about  two  and  one-half  inches  long  and  one-half 
inch  wide,  with)  the  edges  composed1  of  thick  granulat- 
ing tissue.  From  the  center  of  the  ,wound  oozed  a  thick 
creamy  pus.  A  chain  of  enlarged  glands  ran  parallel  to  the 
outer  border  of  the  sternocleidomastoid  muscle  with  one 
enlarged  gland  beneath  the  lower  angle  of  the  wound.  Al- 
ready a  tendency  for  the  dissemination  of  the  tubercular  pro- 
cess made  itself  evident  by  the  appearance  of  two  distinct 
lupus  spots  on  the  shoulder  and  chest.  I  did  not  seek  to  clear 
the  mixed  infection  by  vaccine  before  beginning  with  the 
tuberculin  treatment,  owing  to  the  tendency  for  the  dissem- 
ination of  the  tubercular  process  and  the  length  of  time  that 
the  mixed  infection  had  persisted  (nearly  three  months). 
I  have  here  inserted  a  chart  showing  nearly  the  entire 
course  of  treatment  in  this  case.  I  did  so  because  of  several 
other  important  points  which  the  case  illustrates  and  which 
come  up  in  the  treatment  of  children. 

Child  R    Age  17  ,mos.,  male,  diagnosis — tubercular  adenitis. 
1915 


No. 

Quant. 

Reaction 

Date 

No. 

Dil. 

per 

c.  c. 

Local 

Temp 

Wgt. 

Feb. 

15 

1 

IV 

0. 

10* 

0 

104. 

5 

20   Ibs. 

19 

2 

ft 

0. 

12* 

0 

103. 

8 

22 

3 

" 

0. 

16* 

0 

103 

25 

4 

tt 

0 

.22*  - 

h++t 

103. 

6 

Mar. 

5 

5 

(I 

0. 

10 

0 

-  102. 

8 

9 

6 

a 

0. 

12 

0 

101. 

4 

14 

7 

tt 

0. 

14 

0 

100. 

4 

21 

8 

it 

0. 

18 

0 

100 

*  To    hasten    the    treatment    the    increase   was    increased    at    every 
inoculation.        \ 

fThe  distinct  local  reaction  indicates  that  the  slightly  greater  rise 
in  temperature  is  a  constitutional  reaction. 


FIG.  10. — AN  EXAMPLE  OF  HARD  CICATRIZED  GLANDS  AFTER  CONNECTIVE 
TISSUE  CHANGE. 

This  scar  is  the  result  of  an  operation  for  the  removal  of  a  large 
mass  of  glands  in  the  supraclavicular  region.  The  patient  applied  for 
treatment  six  months  after  the  operation  on  account  of  the  failure  of  the 
wound  to  close.  It  had  formed  a  wide  granulating  surface,  and  had  the 
appearance  of  a  mass  of  glands  in  the  cervical  region. 

The  patient  is  still  under  treatment.  Both  the  operation  and  the 
fact  that  she  is  Italian  are  responsible  for  a  very  high  degree  of  hyper- 
susceptibility,  which  is  making  the  tuberculin  treatment  unusually  pro- 
longed in  her  case,  although  the  wound  promptly  closed  after  a  few 
weeks  of  treatment.  These  glands  cannot  completely  absorb,  not  on 
account  of  any  deficiency  in  the  therapeutic  value  of  tuberculin,  but 
because  cicatrized  connective  tissue  rarely  absorbs.  After  the  hyper- 
susceptibility  is  removed  by  tuberculin,  a  small  incision  will  be  suffi- 
cient to  remove  the  mass  of  cicatrized  glands.  The  healing  of  the  inci- 
sion by  primary  union  will  be  no  less  assured  than  in  the  case  of  any 
other  non-infectious  operation. 


FIG.  17. — SHOWS  THE  DIFFERENCE  BETWEEN  A  EADICAL  OPERATION  BE- 
FORE TUBERCULIN  TREATMENT  AND  A  COSMETIC  OPERATION  AFTER 
TUBERCULIN  TREATMENT. 

The  scar  was  very  prominent  when  the  patient  first  presented  herself 
for  treatment  at  the  New  York  Polyclinic  Hospital,  four  months  after 
the  radical  operation  performed  elsewhere.  The  angle  of  the  scar  was 
suppurating  at  the  time.  In  order  to  show  the  extent  of  the  incision 
for  the  radical  operation  it  had  to  be  painted  with  iodine  just  before 
this  photograph  was  taken,  so  much  has  the  scar  absorbed  during  the 
tuberculin  treatment. 

This  photograph  illustrates  another  bad  feature  of  the  radical  opera- 
tion, especially  when  the  chain  of  glands  extends  over  the  region  of  the 
spinal  accessory  nerve.  Evidently  the  nerve  was  injured  during  the 
operation  with  the  resulting  dropped  shoulder.  The  nerve  supply  to 
the  deltoid  muscle  was  also  injured  as  there  is  very  limited  motion  to 
the  shoulder  with  considerable  atrophy.  The  scar  resulting  from  the 
removal  of  the  submaxillary  gland  is  barely  visible. 


FIG.  18.— OPEN  TUBERCULAR  GLANDS — CAN  A  RADICAL  OPERATION  CURE 
THIS  PATIENT? 

The  tubercular  process  is  not  only  in  the  suprasternal,  supraclavi- 
cular  and  anterior  cervical  glands  but  in  the  superficial  chain  along  the 
inferior  border  of  the  lower  jaw  from  the  right  ear  lobe  to  the  chin, 
also  involving  the  submaxillary  gland  on  that  side. 

Because  of  a  very  high  degree  of  hypersensitiveness  the  treatment  of 
this  patient  was  very  long  drawn  out. 


FIG.  19. — OPEX  TUBERCULAR  GLANDS — CAN  A  RADICAL  OPERATION  CURE 

THIS  PATIENT? 

Following  an  operation  for  the  removal  of  a  mass  of  tubercular 
glands  in  the  right  axilla,  extensive  suppuration  took  place  in  the  inci- 
sion, soon  followed  by  the  appearance  of  tubercular  glands  in  the  neck, 
as  shown  in  this  illustration. 

The  susceptibility  at  the  commencement  of  treatment  was  very  high, 
rendering  the  treatment  longer  than  usual. 


FIG.  20. — ILLUSTRATES  A  EADICAL  OPERATION  WITH  EXTENSIVE  KECUR- 
EEXCE  A  FEW  MONTHS  AFTER  THE  OPERATION. 


FIG.  21. — ILLUSTRATES  A  RADICAL  OPERATION  WITH  IMMEDIATE  RECUR- 
RENCE, WITH  THE  EXTENSION  OF  THE  PROCESS  TO  THE  APEX  OF  THE 
LUNG. 


The  patient,  a  young  man  thirty  years  of  age,  born  in  the  United 
States,  a  clerk  by  occupation,  had  a  maternal  uncle  who  died  of  pul- 
monary tuberculosis.  Jn  his  childhood  he  lived  with  this  uncle  during 
the  active  stage  of  the  disease.  He  had  measles  ,and  whooping-cough  in 
early  childhood,  and  outside  of  frequent  sore  throats,  was  well  until  his 
sixteenth  year.  Fourteen  years  ago,  he  noticed  (that  the  glands  on  the 
right  side  of  his  neck  (cervical  region)  began  to  swell.  In  six  months 
they  grew  to  such  size  that  an  operation  was  advised,  and  performed 
under  a  general  anesthesia.  One  week  after  this  operation,  the  wound 
suppurated,  swellings  appeared  in  the  parotid  region  in  the  supraclavi- 
cular  region,  and  in  the  entire  posterior,  cervical  chain.  These  all  broke 
down,  so  that  after  five  months  of  invalidism,  another  operation  was 
declared  necessary,  and  performed  under  a  two-hour  general  anesthesia. 
The  patient  stated  that  the  surgeons  declared  "  that  it  was  necessary 
to  go  down  to  the  jugular  vein  and  to  the  lung  in  order  to  remove  all 
traces  of  the  disease."  A  month  after  this  operation,  four  or  five 
"  lumps  "  appeared  on  the  same  side  in  the  posterior  cervical  region, 
which  he  carried  for  five  years,  ,being  unable  all  that  time  to  wear  a 
collar  on  account  of  their  awkward  position  and  the  sentitiveness  of 
the  scars.  Seven  years  ago,  these  swellings  suddenly  began  to  sup- 
purate. An  operation  was  again  performed  under  general  anesthesia. 
Three  days  after  this  operation,  the  whole  wound  broke  open  with  a 
great  deal  of  sloughing  of  tissues.  The  patient  declared  that  for  three 
months  "  the  hole  in  the  side  of  his  neck  was  large  enough  to  admit  a 
fist."  After  a  great  deal  of  local  treatment  lasting  over  a  period  of  nine 
months  the  wound  finally  granulated  and  closed.  Fig.  10  shows  the 
extensive  scarring  of  the  side  of  the  neck  which  was  the  seat  of  the 
tubercular  process  up  to  the  present. 

In  June,  1916,  or  five  months  before  the  patient  was  referred  to  me 
for  tubc'iriilin  treatment,  he  noticed  that  the  right  side  of  his  neck  was 
rapidly  swelling,  becoming  steadily  larger  until  the  mass  occupied  the 
entire  side  of  his  neck  as  shown  in  Fig.  23.  Treatment  was  commenced 
at  once.  And  although  these  glands  were  closed,  1  began  with  the 
fourth  dilution  en  account  of  the  previous  radical  operations.  He  ran 
a  slight  temperature  when  he  first  started,  going  up  to  99.4°  F.  by 
mouth  every  afternoon.  There  were  several  local  reactions  after  the 
first  few  treatments.  After  the  eighth  inoculation,  he  had  his  first  con- 
stitutional reaction,  in  which  the  temperature  rose  to  ,100°  F.,  the  local 
reaction  being  at  the  same  time  quite  severe  and  the  constitutional 
symptoms  being  very  definite. 

Both  the  local  reactions  and  the  constitutional  reaction  have  greatly 
retarded  his  tuberculin  treatment;  but  it  is  not  the  quantity  of  tuber- 
culin nor  the  frequency  of  inoculations  that  influence  the  therapeutic 
effects  of  tuberculin;  it  is  the  proximity  of  the  dose  to  the  maximum 
tolerance  that  makes  it  most  effective.  Fig.  24  shows  the  same  young 
man  barely  four  months  after  the  beginning  of  the  tuberculin  treatment. 
The  swelling  in  his  neck  has  entirely  disappeared,  he  is  gaining  in 
weight,  and  he  has  returned  to  his  occupation  which  he  is  now  able  to 
pursue  without  interruption. 


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t.i   tfionavi^iiOM  9rf)  bns  noiiiaoq  bi/3W}I'/7B  ligd-t  lo  iiifioo-jii   no  'iBlIo-) 

l.-')ifi^9irn   [eieodg  i9bnu  baorroligq  niB^B  RBVA  /ioiJi;>ti(|o  nA     .oirnuq 
<;   diiv/  noqo  9/Ioid  bmmv/  gfodw  9di  ,noi^B79qo  aid)' Tail  B  ^vr;i> 
09'fdj  tol  i/;d)  Iwtfil'jgb  inoitfiq  yfIT     .89i/«aii  lu  jmiikmolr-.  lo  IB-)!) 

irrbc  oi  /(yjroiro  agisl  %C7/  ^')9n  aid  lo  9bia  gdJ1  ni  olod  9dd^  "  edjrioirr 
•trciu  lo  bohgq  B  1970  gnii^Bl  JnenrfrBgiJ  IBOO!  lo  I69b  ^Ba-tg  t>»  -igJlA     ".jxil 
•n)i   r.-tnnlf.  Of    .§i1     .boeola   bnn  bgJBlunfi-ig  yJLBnil  bni/ow  adi 
••ii)  lo  JB9-i  art*  en?/  doidw  jJagn  gdi  lo  sbia  9dJ  lo  gnrmi 

.Jn9R9iq  nifl  oJ  qr;  ^r-.o-jo-i 
am  oj  bgiialoi  8Bv/  Jnoitaq  9dJ  9-iolg.J  ariinom  9yft  -to  .OJftf  ,<jnnl-  nl 

if-joir  aid  lo  obi*  idyh  adl  i«d>  bgoilon  ad  ,in9in)nod  niln-rfsdnl  TO! 
adj   baiquaao  asfioi  9dj  Him/  -tygiRl  ylibiieis  gnimo-vtil  .^aillav/-   /fbiqB-r 
b93ff9inmoa  BBW  InemifsgiT    .S£  .§i1  ni  nwoxte  es  iasn  Bid  io  .JJ.IH 'otilno 
.Jrv/    fiB^ad   i   (fiecof9  slaw  sbnfilg  sasriJ  d^uoiljlB    bnA      .•*•• 

.anoilB-wqo  luaibsi  euoiysiq  9di  lo  innoooj;  no  nottulib 
7'1   .'H      i-.ee  o*  qu  Snio^  ,b9iiBJa  dain   9d  ngdw  yusii-.^im-.t 

-•too  i.-iB  r.irf  barf  »if  .HOfJalwoooi  rild^b  ad*  igJIA     >];,  >„!  h ,',,  >  v/aTj^'fl 

./*  "001  o*  9,01  9-,ui«19qm9i  add  doidy,  ni  .„„,-; ,,,,-,   l.rroiiulir, 

J.fciio-)   9((1   bnn  9W/SH   9*inp   9mit  9a,Ba  9d*    ),    -.,,;.„ I 


. 

•r/Bd  noitown  rBnoit»tii«aoo  9dj  boa  anoUoam  IBOO!   1ff;  , 
tfiteaup  Sffj  *0£r  e{ 
t  odJ  wn^Rnj  J(MU 
edl  oi  9«ob  ,di  lo 


lo  tfiteaup  Sffj  *0£r  e{  H  jffd  .in,mjB9li  ni[u,,.)(Il;j  .: 
•' 


lo 
omn.  edi  e-,oda  *2  .8iT     .9vlJwR3  ,80ra  JZ  Wilafn  }t;(ft 

"•.mtB^t  iffo-mdnl  edi  lo  ar,mni§ed  o.ii  ,,,n:  8rf*nom  TOO1  ^sd  nnrrr 
:-   9d    .b9-rB9qq«,ib    ylonino   6«,l    *„„   ,if(    n{ 
'  '"f  fhhlw  aif  f)fin  .. 


FIG.  22. — POST-OPERATIVE  EECURRENT  GLANDS. 

This  case  illustrates  the  futility  of  any  operation  which  aims  to 
remove  the  local  manifestations  of  a  constitutional  disease.  (See  pages 
83  and  84). 


FIG.  23. — POST-OPERATIVE  KECURREXT  GLANDS. 

The  right  side  of  the  neck  of  same  patient  as  Fig,  22  when  tuberculin 
treatment  was  commenced. 


TUBERCULOSIS  OF  THE  GLANDS        81 

Mar.  25  0  IV 

29  10  " 
Apr.  5  11  " 

12  12  " 

16  13  " 
19  14  " 
26  15  " 

May   3  16  " 

7  17 

10  18  " 

17  19 

24  20  " 

31  21  " 

June  7  22  " 

11  23  " 
19  24  " 
22  25  " 
26  26  " 

30  27  " 
July  6  28  " 

NOTE  1.  The  first  four  inoculations  represent  an  increase  of  the 
increase  at  every  inoculation  instead  of  at  every  other  inoculation.  1 
did  this  in  order  to  reach  the  maximum  of  tolerance  as  soon  as 
possible  having  begun  with  the  fourth  dilution,  because  it  was  a 
post-operative  case.  I  felt  that  if  the  hypersusceptibility  happened  not 
to  be  increased  by  the  operation  there  would  be  an  unnecessary  delay 
in  reaching  the  maximum  tolerance.  A  distinct  reaction  after  the 
fourth  inoculation  pointed  to  the  fact  that  the  beginning  of  treatment 
with  the  fourth  dilution  was  correct  in  this  case,  and  that  from  the 
start  I  was  fairly  near  the  maximum  of  the  child's  tolerance.  That 
explained  the  rapid  drop  in  temperature  from  the  very  beginning  of 
treatment.  The  reason  why  I  considered  103.6°  F.  as  a  distinct  con- 
stitutional reaction  was  the  fact  that  there  was  a  severe  local  reaction 
accompanying  the  rise  in  temperature  of  0.6  of  a  degree  higher  than 
the  maximum  temperature  for  three  or  four  days  previous  to  this  inocu- 

JTemperature  record  neglected  but  slight  local  reaction  present, 
hence,  dose  not  increased. 

([Temperature  reaction  after  this  inoculation  proves  that  a  reac- 
tion had  occurred  after  last  dose. 

fiThis  dose  should  have  been  0.48  c.c.  which  might  have  avoided 
the  reaction. 

6 


0.22 

0 

100.2 

0.28 

+ 

t          22.5  Ibs. 

0.28     -t 

-+  + 

102.211 

0.18 

0 

100 

0.20 

0 

100.4 

0.22 

++ 

101.8 

0.14 

0 

Normal 

0.16 

0 

u 

0.18 

0 

a 

0.20 

+'+ 

"          23.5   Ibs. 

0.24 

+ 

u 

0.28 

+ 

ti 

0.34 

++ 

"                          > 

0.40 

0 

a 

0.50H 

-J-_l_ 

102.4         

•      V     V     || 

0.34 

0 

Normal 

0.36 

0 

a 

0.38 

0 

tt 

0.42 

0 

" 

0.46 

0 

"          25.5   Ibs. 

82  TUBERCULIN  AND  VACCINE 

lation.  If  there  were  no  local  reaction  at  the  point  of  inoculation  on 
the  arm,  even  a  much  higher  rise  would  not  be  considered  a  constitu- 
tional reaction,  but  would  be  attributed  to  a  larger  amount  of  absorp- 
tion from  the  wound  area  or  to  some  intestinal  derangement,  etc.,  occur- 
rences which  are  so  frequent  in  children  at  that  age. 

Analysis  of  the  tenth  inoculation  which  was  given  on  the  29th  of 
March,  illustrates  a  common  occurrence  in  the  treatment  of  children 
where  the  mother  has  all  the  household  duties  and  the  care  of  the 
patient  on  her  own  hands.  When  the  mother  brought  the  child  on  April 
5th,  I  found  a  mild  reaction  as  represented  by  one  plus  (-}-)  from  the 
previous  inoculation,  the  mother  reporting  that  she  was  too  busy  to 
take  temperatures.  I  therefore  repeated  the  same  dose  on  the  5th  of 
April  that  I  gave  on  the  29th  of  March  for  this  reason:  with  a  local 
reaction  present,  there  might  or  might  not  have  been  a  constitutional 
reaction,  after  the  previous  inoculation.  If  there  was  a  constitutional 
reaction,  the  same  dose  will  produce  a  constitutional  reaction  again. - 
The  second  constitutional  reaction  may  be  slightly  more  severe,  but 
will  avoid  too  great  a  drop  in.  the  dose  in  case  it  was  found  that  no 
reaction  had  occurred.  In  this  case,  there  was  a  severe  local  reaction 
and  a  moderate  constitutional  reaction,  proving  that  the  dose  previous 
had  also  produced  a  reaction.  But  if  the  eleventh  inoculation  had  not 
produced  a  reaction,  there  would  have  been  a  loss  of  one  inoculation, 
whereas,  if  we  had  not  made  this  test  and  the  eleventh  inoculation 
would  have  been  0.18  we  would  have  lost  nearly  one  month  of  treat- 
ment before  the  maximum  would  again  have  been  reached.  It  is  always 
advisable  in  case  of  a  doubtful  constitutional  reaction  to  repeat  the  last 
dose  before  reducing  the  amount  of  tuberculin. 

After  the  fourteenth  dose,  on  April  19,  there  was  a  rise  in  tempera- 
ture to  101°  F.  which  I  considered  a  distinct  reaction  on  account  of 
the  local  reaction  present.  Owing  to  the  fact  that  this  reaction  occurred 
so  soon  after  the  last  one,  a  larger  reduction  in  dose  than  usual  was 
made;  that  is,  I  reduced  the  dose  to  the  amount  to  which  it  would 
have  been  reduced  had  the  reaction  occurred  after  the  first  time  0.22  c.c. 
had  been  administered,  as  at  the  ninth  inoculation.  Subsequently,  and 
for  the  same  reason,  I  increased,  by  0.02,  the  three  following  inocula- 
tions instead  of  only  two,  and  after  the  eighteenth  inoculation,  continued 
in  the  usual  manner.  However,  on  account  of  the  local  reactions,  occur- 
ring four  times  in  succession  after  the  eighteenth  dose,  the  inoculations 
could  be  given  only  once  a  week.  After  the  twenty-third  inoculation, 
there  was  a  distinct  constitutional  reaction  occurring  as  a  result  of  an 
error  in  the  amount  of  the  increase.  There  should  have  been  an  increase 
of  0.08  c.c.  instead  of  0.10  c.c.  Although  the  rise  of  temperature  was  to 
102.4°  F.  the  constitutional  symptoms  were  mild,  the  rise  in  tempera- 
ture in  a  child  at  that  age  being  usually  out  of  proportion  to  the  cause. 
The  usual  indications  were  followed ;  that  is,  after  a  wait  of  a  full  week, 
the  treatment  was  resumed  with  an  amount  of  tuberculin  equal  to  the 
third  last  inoculation  with  the  increases  from  /there  on  as  at  the  begin- 
ning of  the  treatment. 


TUBERCULOSIS  OF  THE  GLANDS  83 

From  the  end  of  April,  the  wound  began  to  contract  and  the  dis- 
charge diminished  day  by  day  until  the  beginning  of  June,  when  the 
wound  closed  completely.  After  the  inoculation  of  June  11,  it  discharged 
slightly  from  the  upper  angle  but  soon  closed  again  and  never  reopened. 

The  treatment  was  continued  without  any  further  interruption  until 
the  end  of  November,  at  which  time  no  trace  of  disease  remained,  except 
the  linear  scar  marking  the  place  of  the  operation.  It  may  be  noted  that 
my  original  conclusions  as  to  the  mixed  infection  were  correct.  The 
wound  was  so  shallow  that  with  the  disappearance  of  the  tubercular 
process,  the  consequent  improvement  of  the  general  health  was  sufficient 
to  overcome  the  mixed  infection. 

The  following  case  illustrates  the  futility  of  any  opera- 
tion which  aims  to  remove  the  local  manifestations  of  a  con- 
stitutional disease. 

The  patient,  a  young  man  thirty  years  of  age,  born  in 
the  United  States,  a  clerk  by  occupation,  "had  a  maternal 
uncle  who  died  of  pulmonary  tuberculosis.  In  his  childhood 
he  lived  with  this  uncle  during  the  active  stage  of  the  disease. 
He  had  measles  and  whooping-cough  in  early  childhood,  and 
outside  of  frequent  sore  throats,  was  well  until  his  sixteenth 
year.  Fourteen  years  ago,  he  noticed  that  the  glands  on.  the 
right  side  of  his  neck  (cervical  region)  began  to  swell.  In 
six  months  they  grew  to  such  size  that  an  operation  was  ad- 
vised, and  performed  under  a  general  anesthesia.  One  week 
after  this  operation,  the  wound  suppurated,  swellings  ap- 
peared in  the  parotid  region  in  the  supraclavicular  region, 
and  in  the  entire  posterior,  cervical  chain.  These  all  broke 
down  so  that  after  five  months  of  invalidism,  another  opera- 
tion was  declared  necessary,  and  performed  under  a  two- 
hour  general  anesthesia.  The  patient  stated  that  the  stuv 
geons  declared  "  that  it  was  necessary  to  go  down  to  the 
jugular  vein  and  to  the  lung  in  order  to  remove  all  traces 
of  the  disease."  A  month  after  this  operation,  four  or  five 
"  lumps  "  appeared  on  the  same  side  in  the  posterior  cervical 
region,  which  remained  for  five  years.  He  was  unable  all 
that  time  to  wear  a  collar  on  account  of  their  awkward  posi- 
tion and  the  sensitiveness  of  the  scars.  Seven  years  ago, 
these  swellings  suddenly  began  to  suppurate.  An  operation 
was  again  performed  under  general  anesthesia.  Three  days 


84  TUBERCULIN  AND  VACCINE 

after  this  operation,  the  whole  wound  broke  open  with  a 
great  deal  of  sloughing  of  tissues.  The  patient  declared  that 
for  three  months  "  the  hole  in  the  side  of  his  neck  was  large 
enough  to  admit  a  fist."  After  a  great  deal  of  local  treat- 
ment lasting  over  a  period  of  nine  months  the  wound  finally 
granulated  and  closed.  Fig.  22  shows  the  extensive  scarring 
of  the  side  of  the  neck  which  was  the  seat  of  the  tubercular 
process  up  to  the  present 

In  June,  1916,  or  five  months  before  the  patient  was 
referred  to  me  for  tuberculin  treatment,  he  noticed  that  the 
right  side  of  his  neck  was  rapidly  swelling,  becoming  steadily 
larger  until  the  mass  occupied  the  entire  side  of  his  neck  as 
shown  in  Fig.  23.  Treatment  was  commenced  at  once.  And 
although  these  glands  were  closed,  I  began  with  the  fourth 
dilution  on  account  of  the  previous  radical  operations.  He 
ran  a  slight  temperature  when  he  first  started,  going  up  to 
99.4°  F.  by  mouth  every  afternoon.  There  were  several  local 
reactions  after  the  first  few  treatments.  After  the  eighth 
inoculation,  he  had  his  first  constitutional  reaction,  in  which 
the  temperature  rose  to  100°  F.,  the  local  reaction  being  at 
the  same  time  quite  severe  and  the  constitutional  symptoms 
being  very  definite. 

Both  the  local  reactions  and  the  constitutional  reaction 
have  greatly  retarded  his  tuberculin  treatment ;  but  it  is  not 
the  quantity  of  tuberculin  nor  the  frequency  of  inoculations 
that  influence  the  therapeutic  effects  of  tuberculin ;  it  is  the 
proximity  of  the  dose  to  the  maximum  tolerance  that  makes 
it  most  effective.  Fig.  24  shows  the  same  young  man  barely 
four  months  after  the  beginning  of  the  tuberculin  treatment. 
The  swelling  in  his  neck  has  entirely  disappeared,  he  is  gain- 
ing in  weight,  and  he  has  returned  to  his  occupation  which 
he  is  now  able  to  pursue  without  interruption. 


FIG.  24. — POST-OPERATIVE  EECURRENT  GLANDS. 

The  right  side  of  the  neck  of  same  patient  as  Fig.  22  four  months 
after  tuberculin  treatment  has  been  administered. 


CHAPTER  IV 
BOXE  AKD  JOINT  TUBERCULOSIS 

The  subject  of  bone  and  joint  tuberculosis  stands  next 
in  importance  to  pulmonary  tuberculosis.  And  that  only  as 
regards  the  number  of  cases  afflicted,  for  it  stands  second 
to  none  in  the  gravity  of  the  problem  it  presents.  Attack- 

pulmonary 

ing  as  it  does  its  victims  in  childhood  and  early  adolescence,  tuberculosis 
it  at  once  affects  the  individual  as  to  his  entire  future  exist-  manySmore 
ence,  no  matter  how  mild  a  course  the  disease  mav  run.  victims> bone 

and  joint 

On  the  one  hand,  it  prevents  the  proper  fundamental  edu-  tuberculosis 
cation  which  one  can  acquire  only  at  that  age ;  and  on  the  a  probiem  * 
other  hand,  it  disorganizes  his  phvsical  makeup,  interfer-  bothwlth 

regard  to  the 

ing  with  or  even  preventing  any  occupation  which  would  effect  of  the 
keep  him  from  becoming  a  burden  on  society.      There   is  the  victim, 
nothing  so  much  the  subject  of  pitv  as  a  cripple,  no  matter  andwith 

regard  to  the 

what  the  cause  may  be.  But  when  added  to  the  deformity  status  of  the 
we  have  invalidism,  as  in  a  case  of  tuberculosis  of  the  joint,  the  community, 
it  is  lamentable.  A  physically  deformed  individual  in  the 
course  of  years  becomes  accustomed  to  the  deformity  and 
with  the  finding  of  an  occupation  that  has  become  suited  to 
his  condition,  may  even  learn  to  enjoy  the  pleasures  of  life 
with  but  an  occasional  sting  coming  from  the  consciousness 
of  his  being  deformed.  But  when  this  deformity  is  caused 
by  tuberculosis,  especially  open  tuberculosis,  with  discharg- 
ing sinuses,  the  gradual  diversion  of  the  mind  towards  the 
ordinary  pursuits  is  prevented  by  the  necessity  of  constantly 
nursing  his  wounds  and  by  the  pain  and  discomforts  which 
confine  him  to  his  bed  or  to  limited  activity  beyond  it. 

In  its  progress,  medical  science  seems  to  have  over- 
looked this  pitiful  army  of  suffering  children.  The  best 
proof  that  the  profession  seems  to  have  abandoned  these 
unfortunates  as  hopeless,  is  the  tendency  to  convert  hos- 
pitals for  tuberculosis  cripples  to  "  homes "  for  crippled 


86 


TUBERCULIN  AND  VACCINE 


Up  to  the 
present  time 
these  "homes" 
can  only 
accommodate 
a  small 
fraction  of 
the  victims. 


children,  with  the  establishment  of  educational  systems. 
The  name  "  home  "  to  signify  the  permanency  of  residence 
and  the  institution  of  the  educational  system  has  come  in 
answer  to  the  law  requiring  universal  education.  Fortun- 
ately it  also  serves  the  greater  purpose  of  occupying  the 
minds  of  these  sufferers  for  at  least  part  of  the  ^lay  and  of 
diverting  them  from  their  miseries. 

The  number  of  children  taken  care  of  in  "  homes  "  is 
insignificant  in  comparison  with  the  great  army  of  crippled 
children  throughout  the  land,  who  are  unable  to  get  accom- 
modations in  such  "  homes."  And  if  the  lot  of  those  in 
the  "  homes  "  and  hospitals  is  so  pitiful,  what  can  be  the  lot 
of  those  children  who  are  kept  in  the  homes  of  the  poor? 
How  much  care  and  attention  can  a  crippled  child  get  in 
the  home,  where  the  burden  of  the  care  of  a  number  of  other 
children  falls  upon  the  mother  in:  addition  to  the  care  of  the 
home,  and  where  even  the  support  of  the  family  frequently 
falls  to  her  lot  ? 

In  the  case  of  bone  and  joint  tuberculosis,  an  efficient 
remedy  would  be  welcomed  almost  as  enthusiastically  as 
one  for  pulmonary  tuberculosis.  What  then  has  prevented 
the  wider  adoption  of  tuberculin  in  the  treatment  of  bone 
and  joint  tuberculosis  ?  With  the  brilliant  results  obtained 
by  the  use  of  bismuth  paste,  as  [reported  by  Beck,  con- 
stantly before  us,  why  has  it  not  been  more  widely  adopted 
by  the  medical  profession  ?  No  one  can  doubt  the  efficiency 
of  Bier's  hyperemia  in  tuberculosis  of  the  bones  and  joints; 
nor  can  we  question  the  veracity  of  its  author's  reports  of 
his  success  in  a  large  number  of  cases.  Why  have  we  not 
adopted  this  method  more  generally  in  the  treatment  of  the 
bone  and  joint  condition  ?  Favorable  reports  from  the  use 
of  vaccines  in  discharging  sinuses  are  coming  from  unques- 
tionable sources,  especially  from  England.  What  is  the 
reason  that  we  are  so  slow  in  adopting  the  vaccine  treat- 
ment of  these  conditions? 

There  is  but  one  answer  to  all  these  questions  and  that 


BOXE  AXD  JOINT  TUBERCULOSIS  87 

is :  That  in  attempting  the  use  of  any  one  of  these  methods, 
we  have  neglected  to  study  its  mode  of  action  and  have 
looked  upon  it  in  the  nature-  of  a  "  cure-all."  We  have  so 
far  failed  most  hopelessly  in  the  recognition  of  the  multi- 
plicity of  processes  that  constitute  a  joint  tuberculosis  with 
discharging  sinuses.  We  know  that  the  underlying  cause 
is  the  tubercle  bacilli  but  the  condition  ceases  to  be  a  purely 
tubercular  inn  animation  as  soon  as  there  is  destruction  of 
the  joint  lining,  with  affection  of  the  bone  substance.  We 
have  now  to  deal  with  a  changed  structure,  which  has  its 
bearing  upon  the  mechanism  of  the  joint  involved  and  The  profession 

.  .  ,.  ,  ,  has  overlooked 

which  is  quite  apart  irom  the  tubercular  process.     In  other  the  multiplicity 
words,  any   agent,  however  marvelous  in  its  action,   if  it  °nvp0rj°ceedsse 
were  to  remove  the  affection  completely  and  at  once,  would  in  bone 

•ni  11  c       i     /•  TIT-       tuberculosis. 

still    leave    the    problem    01    deformity    unsolved.       is    it 
just  to  condemn  such  a  therapeutic  agent,  because  in  remov- 
ing the  infection  it  failed  to  restore  the  function  of  the 
joint  ?     And  still  that  is  just  what  is  being  done  in  failing 
to  adopt  any  one  of  the  above  mentioned  methods  of  dealing 
with  tubercular  joints  or  bones;  and  so  long  as  we  persist  The  elements 
in  discarding  all  therapeutic  measures  which  do  not  accom-  formation  of  * 
plish  a  complete  cure  all  at  once,  so  long  will  we  fail  in  our  tuberculosis 
treatment  of  these  cripples.     Such  a  therapeutic  agent  will  bones  are: 
never  be  discovered,  for  it  aims  at  the  accomplishment  of 
diversely  different  objects.     But  on  the  other  hand,  if  we 
recognize    the   complexity   of   the   processes    involved,    and 
the  nature  of  each  of  these  processes,  we  shall  realize  at 
once  how  near  at  hand  is  the  complete  cure  of  nearly  every 
case. 

Let  us  consider  the  various  processes  involved  in  tuber-  t.  Anemia.— 
culosis  of  a  ioint.     First  and  foremost,  we  have  anemia  of  T,h' dlsease 

'  ot  bone  does 

the  part  involved.     This  anemia  is  responsible  in  most  part  »°t  <=*"? 

for  the  chronicity  of  the  process  and  nothing  that  requires  the  natural 

circulatory  system  for  its  therapeutic  effect  can  be  of  any  hyPerer 

value  unless  this  is  corrected.      Hence,   in  this  condition,  disease  of 
tuberculin  depends  for  its  favorable  effect  upon  the  focal 


88  TUBERCULIN  AND  VACCINE 

hyperemia  that  it  produces  far  more  than  upon  the  immune 
response  it  calls  forth.  (See  Fig.  25.)  It  may  be  that  the 
patient  already  has  sufficient  immune  response  and  the 
failure  of  the  circulation  to  bring  the  products  of  this 
response  to  the  point  of  infection  has  been  responsible  for 
the  progress  of  the  disease.  So  it  happens  that  Bier's  hyper- 
emia has  cured  a  great  many  of  these  cases,  by  increasing 
the  circulation  in  the  affected  joint  and  permitting  the 
patient's  own  Antibodies  to  get  to  the  point  of  the  infection. 

2.  Mixed  Mixed  infection  is  responsible  for  the  continuation  of 

infection. — 

This  may  the  local  condition  over  a  period  of  years,  even  though  the 

JSlprew,  tubercular  process  itself  has  long  since  disappeared  from 
after  the  ^Q  j^^  condition.  Therefore  in  cases  where  the  mixed 

causative 

has  been  infection  is  the  predominant  process  vaccines  have  proved 

remTvTd.  SUCCGSsful.       (See  Fig.    14.) 

3.  serous  ac-  Long   sinuses  and  bone   cavities   will   heal   irregularly 

when  they  show  a  tendency  to  heal,  enclosing  infected  mate- 
best  of  rial  between  the  healed  areas  which  may  stay  quiescent  for 
the  growth  'a       a  while,  but  finally  must  get  an  outlet  and  therefore  sup- 
purate,— producing  a  recurrence  of  what  was  supposedly 
encouraged         a  cured  case.    This  represents  a  condition  where  the  infection 
reach  of  the         being  tubercular,  or  mixed,  has  ceased  ,to  be  a  factor  in  the 
continuation   of   the   process.      The   accumulation   of   irri- 

mechanism 

of  the  tating  materials    in   these  cavities    and    sinuses    continues 

their  existence.  Filling  |these  sinuses  land  cavities  with 
bismuth  paste  prevents  such  accumulation  and  at  the  same 

4.  irregular        time  causes  a  universal  contraction  of  tissues  upon  this  for- 
when*  e^Sn    substance,    producing    complete    healing.      But    even 
spontaneous        Beck  warns  against  the  use  of  bismuth  paste  where  there 

healing  .  . 

once  sets  in,  is  an  active  inflammatory  process  present ;  for  here  the-main 
Irregularly.  cause  of  the  condition  is  a  virulent  bacteria,  and  not  the 
causing  the  mechanical  structure. 

encysting  of  _,  . 

irritating  Ihe  placing  of  an  early  infected  joint  at  rest  will  make 

d"schl?BV»0ry       a  spontaneous  cure  possible  wherever  there  is  a  tendency  for 

such  a  cure,  hence  manv  of  these  patients  have  been  cured 

which  finally  ,  ' 

recurrence.          ov  orthopedic  appliances  alone. 


FIG.   25 


The  amputation  in  this  case  was  not  an  operation  for  an  emergency. 
Would  it  pot  have  been  more  rational  to  have  localized  the  lesion  by  a 
course  of  tuberculin  treatment  before  the  amputation?  That  tuberculin 
would  have  localized  the  lesion  in  this  case  is  beyond  doubt,  for  it  has 
since  demonstrated  its  ability  to  do  so  in  this  case. 

The  patient,  a  ten-year-old  boy,  had  a  negative  family  history.  He 
was  taken  ill  with  tuberculosis  of  the  ankle  when  two  and  one-half  years 
of  age.  After  four  years  of  ailment,  two  years  of  which  he  spent  in  a 
hospital  ward,  the  foot  was  amputated.  There  was  prompt  extension 
of  the  disease  into  the  knee  and  thigh,  the  lower  third  of  the  femur 
being  involved.  He  was  sent  home  from  the  hospital  where  the  ampu- 
tation was  performed,  with  three  discharging  sinuses.  He  was  finally 
admitted  to  the  Home  for  Crippled  Children,  in  Newark,  New  Jersey, 
where  tuberculin  and  bismuth  paste  treatment  was  begun  in  March, 
1916.  The  brace  which  he  had  worn  was  discontinued,  and  a  posterior 
plaster  splint  was  applied  instead.  At  this  writing,  one  of  the  sinuses 
has  completely  healed,  and  the  other  two  are  about  to  close.  The 
patient  has  greatly  improved  in  every  way,  and  it  is  only  a  question  of 
a  few  months  before  he  will  be  discharged  cured.  I  base  this  prognosis 
particularly  on  the  X-ray  findings. 


•  tuna  i'«a 
nsf-  it  Cftl 
itt  uirrad 


n«  -iol  noi)8-H»qo  HB  Jon  <3Jrw  9-;  no  fills  ni  noijjjji/ijfr- 
2.  Jfixed  «  vd  iioioftl.  gd*  bfwilfi'joi  ovr.rf  ol  lutioHu-i  'riom 

infection.  nilnoi!»JfrJ  JfiriT    ?noiliiifrqui«  adJ  a-ioled  inamtwii  niia'/isdi:*  io-^-moo 

This  may  fefi(j  j|  ,fOj  ^ff,;,^  Xmo^ad  ei  9<?fis  f-.iifl  ai  aoi<-^I  oili  b'jxiluool  evjiil  bluow 

.sens  «hli  rri  oe  oh  ol  viilMu  %Ji  b^j.'yijHuorrr/1 
after  the  -*H     .^ioieh[  vlirnul  9viiw«')ff  B  Lc 

causativt  8iB9'^  llfid-yiio  bne  o//i  nail//  'A'AnK  iili  lo  8£«>[noi9ffoJ  rfliv^  tii  n 

has  been  B  ni  Jnsqa  od  rloiiivA  IO-KIB^'/;  ov/i  ,Jn')mIir,  lo  h'usoy  -in..':  -rot^A     .9v.<;  lo 

noisrwdx!)  jqmo-iq  ««•//  eieitT     .bsiBjuqmB  BBW  Jool  orft  .\nirn  iii1 
removea. 

lutool  9fiJ  lo  bij.-lt  -ov/ol  sift  >rfyiiW  hire  99n>(  ori*  it   }o 

3.  Serou  -j/fjmr.  9ifi  sisifv/  Iiitiqwiti  otft  fulfil  siiioif    I 

B    beine  ^IfjinA  8B7?  sH 

best  of  ,^^19-T;  7/»M  ,jfi/57/-jX  iri  ,no-iMir{' )  bsIqqi'iO  lo't  omolT  -jrft  oJ  beJtinib/; 

culture  r  ,daicH.  fli  Hi^id  6«w  ifl'irnJB'rff  -ji^uq   rfiu/ti-.iil  ftrrc   ni!  .odw 

•ioh9i«oq  B  bite  ,b9finiiuo-jai[i  >).'    ii'in-w  bkd  orl   rioirf//-  -tOBid  9iIT     .0161 

is  const?  aoaiinifi  9fft  lo  erio  ,^niii-iv/  ^idJ  iA    .br»oi*;ai  boilqqB  ^i;//  iiiHq^  •;•  trdq 

encourai  qdT     .9aolo   oi    Jirodn    O'u;    crwt    -torfto    oib'bnK    .!  afr.od   vbtofqmoo    asd 

beyond  •  5O  R()itaaup  »  ^laa' si  Ji  bmi  WN  -fi97»  cii  bevo-iqmi  vrir;9'ig  EBd  JnaiJBq 

.fcitioji^o-iq  eid^  9tifcd  1     .Imuo  bo^iBdo'-fli  -id  Hi/,  si!  'ri^Vjd  «iliiioar  v^-i't  n 
mechair  .-'.;!.  if. nil     | 

of  the 
afflicted  ,    OX;j,teilCe. 

.  ~?,j  -;h  |n^.tc  prevents  sv- 
;-.  -<;z 

4-    *"«* 
healing 

When 

spontar 

healing 

once  se 

it  does 

irregul. 

causing 

encysti 

irritati 

inflamr 

discha 

cause 

which  ,i> 

recurr. 


FIG.  25. — THE  EFFECT  OF  THE  REMOVAL  OF  A  LOCAL  LESION  IN  A  CONSTI- 
TUTIONAL DISEASE. 


AND  JOIXT  TUBERCULOSIS  89 

If  it  were  within  our  ability  to  discern  the  predominant 
process  in  each  case,  we  could  apply  these  various  thera- 
peutic methods  singly  with  [success.  However,  the  principal 
cause  of  the  neglect  of  these  methods  was  the  failure  to 
judge  correctly  the  predominant  condition  present  in  every 
case.  So  that  these  various  therapeutic  agents  were  wrongly 
applied  and,  of  course,  were  rapidly  discarded.  Why  not  s-  Deformity.— 

•  o          i  •  Orthopedic 

apply  them  all  in  every  case  f     feurely  the  vaccine  will  not  appliances 
interfere  with  the  action  of  the  bismuth  paste;   nor  will  fre •essential 

to  limit 

tuberculin   interfere  with  vaccine  treatment;  nor  will  im-  functional 

f  .-.-.     .  destruction 

munization  interfere  with  vaccine  treatment;  nor  will  im-  to  a  minimum, 
munization    interfere   with    the    proper   use   of    orthopedic  f0r°the  rest"*1' 
appliances.     Each  one  of  these  therapeutic  measures  men-  the  part 
tioned  above — and  which  will  be  described  in  further  detail  during  the 
later  on — serves  its  own  purpose  and  fortunately  does  not  *"^™^. 
interfere  with  one  another.     ,Their  combined  use  will  lead 
to  greater  results  which  will  not  only  help  the  victim,  but 
also  those  who  fall  within  the  sphere  of  his  influence.     Then 

,         ,      ,,  ,.  ,  .  ,  .  ,    The  combined 

only  snail  we  remove  irom  the  patient  the  consciousness  01   therapy  is 
disease  and  open  the  wider  field  of  employment  to  him.     We   the .only 

rational 

shall  remove  from  his  mind  the  fear  of  transmission  of  the   treatment 
disease  to  posterity,  and  in  a  great  many  instances  remove  combination 
the  barrier  to  matrimony.     And  lastly,  but  not  least,  is  the   o£  pathological 

.  i  .  processes. 

fact  that  in  the  case  of  a  patient  cured  by  tuberculin,  the 
orthopedist  will  be  able  to  decide  the  exact  time  for  the 
removal  of  the  various  appliances.  This  necessarily  always 
had  to  be  a  matter  of  guess,  as  the  orthopedist  was  never 
certain  whether  the  joint  is  merely  quiescent  or  cured,  and 
therefore  frequently  insisted  on  prolonging  the  wearing  of 
these  appliances  for  a  number  of  years,  even  though  the 
patient  seemed  entirely  well.  With  the  danger  of  a  relight- 
ing of  the  infection  removed — the  element  of  guess  is  elim- 
inated— and  both  the  patient  and  the  orthopedist  need  not 
fear  the  removal  of  the  appliances. 


90  TUBERCULIN  AND  VACCINE 

General  Hypersusceptibility 

The  degree  of  Jn  the  tuberculin  treatment  of  bone  and  joint  tubercu- 

hypertus-  losis,  we  have  two  main  varieties  of  processes  to  recognize. 

closed  variety,  where  the  tubercular  process  is  limited 


bone  and  joint  •<••!•  l  i_ 

tuberculosis  in  or  around  the  joint,  the  infection  being  purely  tuber- 

opposuX  cular  in  nature  .and  therefore  remains   more  or  less   cir- 

what  it  is  in  cumscribed  ;   and  the  open  variety,  where  the  destruction 

fuberc^Jsis;  is  considerable  and  where  a  mixed  infection  had   led   to 

iVriety'hlving  an   abscess    formation   which   had   broken   open   upon   the 

the  greater  surface    of    the    body.      The    general    hypersusceptibility 

hyperlus-  holds    the    exact    contrary    position    with    regard    to    its 

ceptibiiity,  decree  in  the  open  and  closed  as  is  true  in  the  glandular 

and  the  open 

variety  tuberculosis.     In  bone  and  joint  tuberculosis  the  greater 

possessing  ..  „.  .  .          ,  1          ,  . 

the  lesser  degree  of  hypersusceptibility  exists  in  the  closed  variety, 

whereas  in  the  open  type,  the  general  hypersusceptibility 

ceptibiiity.  lessens  with  the  length  of  time  that  the  disease  has  per- 
sisted. The  highest  degree  of  hypersusceptibility  most  often 
occurs  in  the  earliest  cases  and  it  is  particularly  emphasized 
that  where  the  diagnosis  is  doubtful  and  the  tuberculin  test 
is  indicated,  a  severe  reaction  might  be  most  detrimental, 
During  the  period  of  lessened  tolerance  after  such  a  reaction 
(negative  phase)  an  extension  of  the  process  is  very  apt  to 
occur.  In  older  cases,  the  tolerance  increases  through  a  long 
series  of  auto-inoculations  and  the  degree  of  hypersuscepti- 
bility varies  from  a  moderate  amount  to  its  absence  alto- 
gether. In  those  cases  where  the  tolerance  is  almost  absent, 
the  tubercular  process  has  been  overcome  by  a  naturally  ac- 
quired resistance.  This  represents  the  class  of  cases  that 
responds  readily  to  the  injections  of  bismuth  paste,  without 
any  other  treatment 


Beginning  Treatment. 

It  follows  from  the  degrees  of  hypersusceptibility  as 
described  above  that  in  early  closed  cases  of  tubercular 
joints,  it  is  best  to  begin  treatment  with  the  fourth  dilution 


CONCLUSION  OF  TREATMENT  91 

and  in  cases  where  the  disease  shows  an  acute  condition.  As  a  general 

,       .          .  ,       .     , .  .  rule  o.ooooi  c.c, 

the  fifth  dilution  is  more  strongly  indicated,     it  is  always  of  OT  is  not 
necessary  to  bear  in  mind  that  the  conversion  of  a  closed  ^Inning 
case  into  an  open  one  is  always  considered  by  the  laity  as  dose  in  the 

, .      .  .  , .    .  i   -••»'••  closed  variety, 

a  distinct  retrogression  in  the  condition  and  11   it  occurs  except  in 
during  the  tuberculin  treatment,  it  might  lead  to  a  discon-  CM'S* where 

tinuation  of  the  treatment.      Since  a  severe  reaction  will  °-°°o°°i  c.c. 
IT-  •         f  i        •  •         of  OT  would 

encourage  the  disintegration  of  tubercular  tissues  and  since  be  more 

disintegrated  tissues  in  a  great  many  instances  cannot  be  a  V1S< 
absorbed,  it  will  lead  to  increased  pain  from  pressure  and 
finally  to  the  breaking  open  on  the  surface  with  the  forma- 
tion of  a  sinus.  It  is  therefore  necessary  to  exercise  a  great 
deal  more  care  in  the  treatment  of  closed  conditions  than  in 
the  treatment  of  open  ones. 

In  the  case  of  open  bone  and  joint  tuberculosis,  "we  have  in  the  open 
by  far  an  easier  problem  to  deal  with.     We  have  channels  tubercufotu1* 
for  drainage ;  the  disease,  as  a  rule,  is  more  effectively  walled   °-°0001  c-c 
off  from  the  surrounding  tissues  and  any  mishap  during  the  always  be  the 
tuberculin  treatment  will  produce  no  serious  results.     We  Jjesinmn* 

dose,  and     in 

can,  therefore,  begin  the  treatment  with  the  fourth  dilution  the  older  cases. 

M  .,.  .  o.oooi  c.c.  of 

in  cases  where  we  suspect  the  hypersusceptibihty  to  exist  to  OT  is  quite 
a  higher  degree,  as  in  very  young  children,  or  in.  cases  of   ' 
early  infection.     In  long  standing  cases,  it  is  quite  safe  to 
begin  with  the  third  dilution. 

Conclusion  of  Treatment 

In  open  joint  and  bone  tuberculosis,  after  the  conclu- 
sion of  treatment  with   OT,   it   is  sufficient  to  administer 
the   usual  course  of  BE   as  advised  in   the  general   plan 
(Chart  III,  page  60).      Even  if  the  sinuses  and  fistulas 
are  still   open,   we  can  discontinue  the  administration  of 
tuberculin   after   0.20   c.c.    of   BE   has   been   administered 
and   continue   the   treatment   of   the  case  as   described   in 
the  third  section  of  this  work.     In  the  case  of  the  closed  Conclusion 
bone    and   joint    tuberculosis,    it   is   'advisable   to   conclude  treatment, 
the  tuberculin  treatment  as  slowly  as  possible.    The  BE  can 


92  TUBERCULIN  AND  VACCINE 

be  administered  by  the  slow  method  (Chart  IV,  page  60) 
and  instead  of  doubling  the  dose  of  0.10  c.c.  pure  BE,  as 
a  final  test,  we  can  continue  the  same  increases  beyond  a 
0.10  c.c.  pure,  until  0.30  or  0.40  c.c.  pure  BE  is  reached. 
The  interval  is  always  a  week,  and  beyond  the  0.10  c.c.  dose 
ten  days  or  two  weeks  may  be  the  length  of  the  intervals. 

Results 

The  results  There  is  no  class  of  patients  that  demonstrate  the  suc- 

"hTuTe'of^he  cess  or  failure  of  ,a  given  therapy  as  definitely  as  those 
combined  afflicted  with  bone  and  joint  tuberculosis.  This  form 

therapy  in  .«.•'•'•  i  i  j: 

bone  and  joint  of  the  disease  is  very  chronic,  and  in  a  large  number  01 
[" .."evident  cases  produces  permanent  invalidism,  in  spite  of  the  usual 
that  it  win  methods  of  treatment,  so  that  when  we  speak  of  results 

require  but  a  • 

short  trial  obtained  by  the  combined  therapy  as  outlined  here,  there 

theWrnn0stVCr  is  no  element  of  guess  used  as  to  the  conclusions.  When 
conservative  a  lnonth  or  two  of  treatment  will  bes;in  to  put  color  and  flesh 

opinion. 

on  an  individual  who  has  been  pallid  and  emaciated  for 
years; — when  three  or  four  months  of  treatment  will  re- 
move pain  and  tenderness  that  have  persisted  for  a  long 
time; — when  a  year  of  treatment  will  close  sinuses  and 
fistulas  that  have  been  discharging  for  a  decade  or  longer, 
and  will  remove  the  individual  from  the  bed  which  he  has 
occupied  for  the  same  length  of  time,  and  again  place  him 
among  normal  human  beings, — there  is  no  element  of  guess 
used  when  we  pronounce  this  therapy  as  most  successful. 

No  hospital  ward  has  a  more  characteristic  appearance 
The  adoption  than  one  where  bone  and  point  tuberculosis  patients  are 
of  treatment0  treated;  and  the  features  which  render  it  so  characteristic 
in  institutions  are  the  lack  of  interest  on  the  part  of  the  doctors  and  nurses, 

where  bone 

and  joint  and  the  pained  or  resigned  expression  on  the  faces  of  the 

is  treated  win      invalids.    The  whole  work  carried  on  in  such  a  ward  can  be 

summed  up  by  the  one  word  "  drudgery  " — change  of  dress- 

resuitsby  ings  from  discharging  sinuses,  weight  and  pulley,  feeding, 

and  ,a  change  of  soiled  linens  form  a  daily  routine.     It  is 

remarkable  how  this  aspect  changes  when  immuno-therapy 


RESULTS  93 

is  instituted  in  such  a  ward.  There  is  no  work  that  raises 
the  enthusiasm  of  the  physicians  so  much  as  the  successful 
application  of  immuno-therapy.  And  once  there  is  a  rise 
in  the  interest  on  the  part  of  the  visiting  physicians,  it  is 
immediately  reflected  in  the  attitude  of  the  nurses  toward 
these  invalids. 

In  the  Home  for  Crippled  Children,  jn  Newark,  New 
Jersey,  this  change  was  most  marked  when  in  October,  1915, 
this  form  of  therapy  was  instituted.  The  nurses  now  feel 
that  their  work  has  been  raised  from  "  drudgery  "  to  a  pro- 
fessional duty,  and  constantly  speak  of  the  results  obtained 
as  "  miraculous."  Doctor  Sidney  A.  Twinch,  through  whose 
efforts  this  therapy  has  been  instituted  at  the  Home  for 
Crippled  Children  in  Newark,  now  rightly  characterizes  the 
former  treatment  of  those  cripples  as  "  The  do-nothing- 
treatment." 

In   the  ambulatory  treatment   of  these  conditions,   the 
results  are  fro  less  brilliant     I  cannot  recall  a  single  case  with  the 
in  a  period  of  seven  years  that  has  proved  an  out-and-out  patience  every 
failure.     There  were  a  few,  that  for  some  unknown  reason  ambulatory 

case  of 

left  in  the  midst  of  treatment;  a  few  more  left  before  the  bone  and  joint 
conclusion  of  treatment,  considering  themselves  cured,  and  *"  curable"8 
then  had  to  return  later  for  the  treatment  of  recurrence. 
But  altogether  these  exceptions  are  so  few  in  number,  and 
these  few  present  such  evident  reason  for  the  seeming  failure 
which  had  no  relation  to  the  therapy  applied,  that  we  could 
pronounce  the  curability  of  bone  and  joint  tuberculosis  as 
complete. 

It  is  true  that  any  one  of  the  processes  going  into  the 
formation  of  tubercular  'bone  disease  may  be  most  prominent 
in  given  cases, — rendering  it  possible  for  the  appropriate 
therapy  to  produce  a  complete  cure.  In  such  instances 
the  other  processes  were  present  in  mild  form,  and  spon- 
taneously disappeared  after  the  eradication  of  the  predomi- 
nant process. 

We  cannot,  however,  depend  upon  the  application  of  a 


TUBERCULIN  AND  VACCINE 


It  is  best  to 
utilise  the 
combined 
therapy  even 
in  cases  where 
it  is  possible 
to  distinguish 
the  predominant 
process. 


single  therapy  for  two  reasons.  In  the  first  place,  it  is  but 
rarely  possible  to  discover  the  predominant  process,  and  the 
choice  of  the  therapy  may  be  wrong  in  the  majority  of 
cases.  In  the  second  place,  two  or  more  processes  play 
equally  important  roles  in  the  vast  majority  of  cases,  mak- 
ing it  absolutely  necessary  for  a  combination  of  therapeutic 
measures  to  produce  a  cure.  It  therefore  follows  that  with 
the  combined  therapy  here  outlined,  maximum  results  can 
be  obtained. 

The  following  are  a  few  characteristic  histories  and 
illustrations  which  will  bring  out  the  essential  points  in  the 
treatment  of  bone  and  joint  tuberculosis.  These  are  cases 
where  the  tubercular  process  itself  was  the  predominant 
factor  in  the  condition.  In  Part  III  ,a  full  description  will 
be  found  of  cases  illustrating  more  particularly  the  factors 
aside  from  the  tubercular  process,  that  form  the  whole  com- 
plex pathology  of  bone  and  joint  tuberculosis. 

A  perfect  example  of  the  value  of  the  utilization  of  the  immune 
response  is  illustrated  in  the  following  history. 

This  patient  lived  in  the  best  of  surroundings — a  trained  nurse  was 
with  him  from  the  onset  of  his  trouble — special  climate,  a  sleeping  porch, 
and  every  conceivable  comfort  were  provided  for  him — he  was  under  the 
best  of  medical  care.  In  spite  of  it  all,  there  was  an  unfavorable  pro- 
gress of  the  disease.  He  is  a  ten  year  old  boy,  has  a  negative  family 
history,  and  was  always  well.  In  December,  1912,  he  sustained  an 
injury  to  his  knee,  which  was  not  thought  to  be  serious,  and  he  only 
occasionally  complained  of  pain.  Four  months  later  the  knee  became 
swollen  and  was  treated  for  effusion.  The  following  month,  in  a 
consultation  at  Johns  Hopkins  Hospital,  it  was  pronounced  tuber- 
cular, although  the  X-ray  failed  to  find  any  evidence  of  it.  A  plaster 
cast  was  applied.  Three  months  later  the  wrist  joint  of  the  right  hand 
was  swollen  and  painful.  The  wrist  was  put  into  a  cast.  The  wrist 
joint  cleared  up  after  fourteen  months  of  immobilization.  The  condi- 
tion of  the.  knee  which  was  not  improving,  was  followed  a  year  and  a 
half  later  by  involvement  of  the  right  hip  joint.  The  process  in  this 
hip  was  very  rapid  and1  acute.  When  the  author  first  saw  the  patient 
(through  the  courtesy  of  Doctor  Sidney  A.  Twinch)  the  boy  had  been 
steadily  confined  to  bed  for  ten  months.  The  right  hip  and  the  right 
knee  were  extremely  swollen,  shiny  and  of  a  bluish  hue.  Both  hip  and 
knee  were  the  seats  of  numerous  fistulous  openings.  The  patient  was 
extremely  emaciated.  Two  months  after  the  institution  of  tuberculin 
treatment  all  sinues  were  closed;  the  pain  and  suffering  disappeared. 
At  this  time,  a  year  and  a  half  since  the  beginning  of  tuberculin  treat- 
ment he  is  in  perfect  health,  weighing  about  forty  per  cent,  more  than 
ne  did  when  tuberculin  treatment  was  begun. 

A  better  example  of  an  insufficient  immune  response  cannot  be  pre- 
sented for  nothing  but  the  stimulation  of  this  immune  response  with 
tuberculin  would  have  availed  in  thia  case. 


FIG.  26. — THE  EFFECT  OF  THE  REMOVAL  OF  A  LOCAL  LESION  IN  A  CONSTI- 
TUTIONAL DISEASE. 

Patient,  a  young  man  twenty  years  of  age. 

This  is  another  illustration  of  the  futility,  to  say  the  least,  of  an 
extensive  operation  for  the  removal  of  a  local  manifestation  of  a  con- 
stitutional affection.  After  the  amputation,  there  was  prompt  extension 
to  the  hip  and  shoulder,  and  although  the  tubercular  condition  was  of 
many  years'  standing,  it  took  but  one  year's  treatment  to  combat  the 
disease  with  final  closing  of  all  the  sinuses.  Thus  this  case  proved  that 
tuberculin  was  effective  not  only  in  limiting  the  process  to  a  local  con- 
dition, but  in  healing  the  local  condition  as  well. 


CHAPTER  V 
KENAL  TUBERCULOSIS 

Neither  experience  nor  the  literature  on  tuberculosis  can  The  literature 

be  said  to  throw  any  light  upon  the  subject  of  the  treatment  of  renal" 

of  renal  tuberculosis  by  means  of  tuberculin.     The  immuno-  tubercul°s's 

^  is  too  meagre 

therapist  is  never  consulted  in  the  early  stages  of  the  disease  to  serve  as  a 


for  two  obvious  .reasons:     The  early  symptoms  bring  the  f 
patient  to  the  genito-urinary  specialist  or  the  gynecologist,  tionofthe 
if  indeed  a  specialist  is  consulted  at  all;  and  again  if  the  tuberculin 
general   practitioner   is  consulted,   the  diagnosis   is  rarely  condition. 
made  until  there  has  been  a  severe  extension  of  the  disease. 
The  early  diagnosis  of  renal  tuberculosis  is  difficult  in  any 
case.     When  we  consider  that  this  disease  falls  in  the  pro- 
vince of  the  genito-urinary  specialist  or  gynecologist,  a  sys- 
temic treatment  like  tuberculin  or  vaccine  administrations 
would  have  to  obtain  spectacular  results  before  it  would  be 
generally   adopted.     And   just  here  the   immuno-therapist 
can  offer  the  least  by  way  of  advice  either  through  his  own 
experience  or  through  the  literature  on  the  subject  of  tuber- 
culin in  tuberculosis. 

A  closer  analysis  of  the  subject  of  renal  tuberculosis  with  in  view 

<••!••  -it  T     •  r     °*  ****  ka<* 

reference  to  the  source  of  infection  and  the  complicity  01  prognosis 
the  structure  of  the  organs  involved  will  no  doubt  bring  home  tuberculosis 
to  the  impartial  reader  the  fact  that  tuberculin  in  genito-  with  the  usual 

i  -i       .       .         i  .  .-m  treatment, 

urinary  .tuberculosis  is  the  most  rational  treatment.      I  hen  there  can  be 
the  few  cases  in  my  own  experience  that  I  can  report  together  "°  °1^1"e:Jon 
with  the  number  of  cases  reported  in  the  literature,  will  suf-  use  of 
fice  to  indicate  that  what  in  theory  may  be  found  rational, 
can  be  brought  about  in  practice. 

As  to  the  source  of  infection:  Tuberculosis  of  the 
genito-urinary  tract  is  not  a  primary  infection.  The  lesion 
first  appears  in  the  kidney  and  then  travels  down  to  the 


96 


TUBERCULIN  AND  VACCINE 


The  source 
of  infection 
in  renal 
tuberculosis  is 
outside  of  the 
urogenital 
apparatus. 


bladder  and  so  on.  But,  how  does  the  tubercle  bacillus  find 
lodgment  in  the  kidney  in  the  first  place?  This  question 
can  have  but  one  answer,  and  that  is:  Through  the  cir- 
culation. The  kidneys  form  the  main  filters  of  the  body.  All 
products  of  digestion  and  assimilation,  internal  secretions  and 
all  else  that  forms  in  the  'body  for  the  utilization  of  the  body 
cells  everywhere,  must  pass  through  the  kidneys ;  and  through 
a  marvelous  mechanism,  the  products  necessary  to  the  organ- 
ism are  allowed  to  pass  on  and  the  poisonous  products,  as 
well  as  the  foreign  material  such  as  bacteria,  are  made  to 
pass  out  of  the  system  by  way  of  the  urine.  Although  it  is 
difficult  to  find  tubercle  bacilli  in  the  circulation,  their 
presence  there  has  been  demonstrated.  When  these  tubercle 
bacilli  pass  through  the  kidneys  during  a  period  of  tempo- 
rary insufficiency  or  of  kidney  irritation  due  to  a  tempo- 
rary over-taxation  caused  by  the  passing  through  of  an 
undue  amount  of  irritating  substances,  tubercle  bacilli  may 
find  lodgment  there  and  start  a  lesion.  The  source  of  infec- 
tion is  usually  somewhere  in  the  lymphatic  system,  especially 
in  the  mesenteric  glands.  [Mediastinal  or  mesenteric  gland 
tuberculosis  may  exist  in  mild  form  undiscovered  and  offers 
the  main  source  of  infection  for  renal  tuberculosis. 

In  view  of  the  existence  of  a  distant  source  of  infection, 
what  are  the  chances  for  recovery  through  surgical  inter- 
ference alone?  The  removal  of  a  kidney  is  an  operation  of 
considerable  magnitude  and  serves  to  increase  the  hyper- 
susceptibility  to  a  high  degree.  The  infection  of  the  remain- 
ing kidney  from  the  original  source  becomes  even  more  likely 
than  the  infection  of  the  first  kidney,  and  we  know  with 
what  frequency  the  infection  of  the  remaining  kidney 
occurs.  Occasionally,  the  patient  is  cured  after  the  removal 
of  the  kidney.  The  source  of  infection  in  that  case  com- 
pletely healed,  so  that  the  removal  of  the  kidney  was  suffi- 
cient to  stop  the  rest  of  the  tubercular  process  just  as  the 
radical  operation  in  the  glands  in  the  neck  does  occasionally 
get  beyond  the  area  of  infection.  However,  so  numerous  are 


FIG.    27 

Patient,  a  boy  of  twelve  years.  His  father  died  of  pulmonary  tuber- 
culosis. His  mother  and  five  other  children  are  in  good  health. 

He  had  whooping-cough  at  the  age  of  four,  scarlet  fever  and  diph- 
theria at  the  age  of  six.  Immediately  after  the  scarlet  fever  pain  devel- 
oped in  the  left  hip,  and  he  had  night  cries.  Six  months  later  he  began 
to  limp  and  for  three  months  was  treated  by  five  different  physicians 
with  liniments,  anti-rheumatic  medicines,  etc.,  until  finally  one  year 
after  the  scarlet  fever  he  developed  pain  and  swelling  on  the  right 
ankle.  He  was  brought  to  the  Home  for  Crippled  Children,  in  Newark, 
New  Jersey,  for  treatment.  Here  a  diagnosis  of  left  tubercular  coxitis 
and  right  ankle  joint  was  made.  The  usual  orthopedic  appliances  were 
applied,  and  his  treatment  was  continued  in  the  O.  P.  Department  for 
one  year.  He  was  then  admitted  to  the  ward  with  the  left  hip  involved 
and  the  right  ankle  discharging  profusely.  Buck's  extension  was  applied 
to  the  hip  and  the  ankle  was  dressed  with  dry  dressings.  During  the 
year  1911,  four  sinuses  developed  on  the  right  hip,  discharging  pro- 
fusely. Two  large  cold  abscesses  formed  on  the  hip  during  1914.  Sev- 
eral of  the  sinuses  healed  on  the  left  ankle.  At  the  time  tuberculin 
treatment  was  begun,  in  October,  1915,  the  four  sinuses  on  the  hip  and 
two  on  the  ankle  were  still  discharging  profusely.  Bismuth  injections 
were  given  three  times  weekly.  The  patient  was  up  on  crutches  by 
February  23,  1916,  A  photograph  of  the  healed  condition  is  shown  in 
Fig.  29,  which  was  taken  in  March,  1916. 


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FIG.  27. 


FIG.  28  is  AN  X-RAY  PHOTOGRAPH  OF  THE  PATIENT  SHOWN  IN  FIG.  27 
AND  SHOWS  THE  TOTAL  DESTRUCTION  OF  THE  HlP  JOINT  WITH 
SINUSES  EXTENDING  INTO  IT. 


PIG.  29  SHOWS  THE  SAME  PATIENT  AS  ix  FIGS.  27  IXD  28  AND  SHOWS  A 
COMPLETE  CURE. 


Patient,  a  boy  eight  years  old.     Family  history  negative. 

In  May,  1914,  pain  and  swelling  developed  in  the  right  ankle,  and 
in  spite  of  wet  dressings  and  an  incision,  which  evacuated  large  quan- 
tities of  pus,  pain  was  incessant  for  fifteen  weeks,  the  child  screaming 
day  and  night  most  of  the  time.  By  this  time  the  left  hip  became  sen- 
sitive. Until  August,  1915,  he  was  treated  in  the  0.  P.  Department  of 
the  Home  for  Crippled  Children,  in  Newark,  New  Jersey.  But  his 
suffering  became  so  intense  that  on  that  date  he  was  admitted  to  the 
hospital  ward.  Buck's  extension  was  applied  to  the  left  leg,  and  dry 
dressings  to  the  right  ankle,  which  was  discharging  a  very  offensive 
pus  from  four  sinuses. 

On  October  14,  1915,  tuberculin  treatment  (my  method)  was  begun 
by  Doctor  Sidney  A.  Twinch,  of  Newark.  On  November  11,  1915,  a 
fluctuation  over  the  outer  aspect  of  the  thigh  threatened  to  break  and 
was  incised  by  Doctor  Twinch.  Two  weeks  later  bismuth  paste  in- 
jections were  begun  and  .administered  twice  weekly,  both  in  the  left 
hip  and  in  the  right  ankle.  After  a  few  bismuth  paste  injections  in 
the  right  ankle,  the  astragalus  came  away  through  one  of  the  sinuses. 
All  sinuses  closed  in  December,  1915.  One  of  them  reopened  two  weeks 
later  but  finally  closed  again.  There  was  an  immediate  response  to 
tuberculin  treatment,  in  this  case  the  child  improving  in  weight  and 
strength,  and  requiring  but  a  comparatively  short  bismuth  paste  treat- 
ment to  close  all  the  sinuses. 


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FIG.  30. 


FIG.  31.— SAME  PATIENT  AS  FIG.  30. 

This  X-ray  of  the  hip  taken  after  bismuth  injection  shows  the 
long  sinuses.  The  stereopticon  X-ray  reveals  the  sinus  going  clear 
around  the  hip  joint.  It  could  be  seen  at  a  glance  that  any  attempt  at 
spontaneous  healing  would  have  rendered  irregular  healing  and  encyst- 
ing of  parts  of  the  sinuses  extremely  liable,  with  consequent  recurrence. 
This  was  prevented  by  bismuth  paste  injections. 


FIG.  32 

This  patient,  a  boy  nine  years  old,  has  a  negative  family  history. 
When  he  was  eight  months  old,  the  baby  carriage  in  which  he  was 
sleeping  fell  down  a  flight  of  stone  steps.  After  this  his  legs  always 
seemed  sensitive  on  handling,  but  he  was  given  no  treatment. 

At  one  year  of  age  he  walked,  and  neither  limped  nor  showed  any 
signs  of  pain  for  six  months.  Then  the  left  hip  became  painful.  The 
tubercular  nature  of  the  condition,  however,  was  not  discovered  until 
April,  1911,  when  he  was  brought  to  the  Home  for  Crippled  Children, 
Newark,  New  Jersey,  after  three  years  of  ailment.  A  plaster  spica 
was  applied  to  the  left  hip,  but  the  condition  became  ,so  acute  that  in 
less  than  two  weeks  he  was  admitted  to  the  hospital  ward,  with  Buck's 
extension  replacing  the  plaster  spica.  During  the  following  few  months 
abscesses  with  resulting  sinuses  developed  all  around  the  hip  and  thigh. 

During  the  following  year  the  abdomen  began  to  grow  very  large, 
with  the  development  of  distinct  signs  of  tubercular  peritonitis.  When 
the  author  first  saw  this  patient  in  October,  1915,  the  boy  had  not  left 
his  bed  in  the  hospital  since  April,  1911.  Five  or  six  fistulous  openings 
around  the  hip  and  thigh  oozed  a  thick  creamy  pus.  The  abdomen  was 
greatly  distended  with  the  liver  and  spleen  reaching  down  to  the  brim 
of  the  pelvis. 

This  case  illustrates  an  extent  of  the  tubercular  process  which  was 
beyond  the  control  of  the  surgeon,  and  what  is  more  serious,  it  seemed 
beyond  the  reach  of  the  patient's  healing  powers.  The  promptness  with 
which  this  patient  responded  to  the  tuberculin  treatment  leaves  no 
room  for  doubt  as  to  the  efficacy  of  tuberculin  in  tubercular  affections. 
The  X-ray  photograph  of  this  patient  (Fig.  33)  shows  the  extent  of, 
the  tubercular  process  in  the  hip;  and  Fig.  34  shows  the  same  patient 
cured,  fifteen  months  after  the  beginning  of  tuberculin  treatment. 


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lo 


FIG.  32. 


FIG.  33. — X-RAY  PHOTOGRAPH  OF  THE  SAME  PATIENT  AS  FIG.  32,  SHOWING 
THE  SINUSES  FILLED  WITH  BISMUTH  PASTE — NOTE  THE  ALMOST 
COMPLETE  DESTRUCTION  OF  THE  HIP  JOINT. 


FIG.  34. — SHOWS  THE  HEALED  CONDITION  OF  THE  SAME  PATIENT  AS  FIG. 
32  ALL  THE  SINUSES  CLOSED,  THE  SPLEEN  BARELY  FELT  BELOW  THE 
MARGIN  OF  THE  RIBS,  THE  LIVER  ONLY  Two  INCHES  BELOW,  THE 
ABDOMEN  FLACCID, — THE  BOY  TO  ALL  APPEARANCES  IN  PERFECT 
HEALTH. 


REXAL  TUBERCULOSIS  97 

the  cases  where  there  is  no  benefit  to  the  patient  or  where 
there  is  extension  of  the  disease  following  the  removal  of  the 
kidney,  that  the  operation  cannot  be  called  a  success. 

As  to  the  complicated  mechanism  of  the  organs  involved : 
It  is  well  known  ,that  the  treatment  of  any  part  of  the  genito-  The  urogenitai 

.. .  „       ,  -.  , .  .  tract  is  so 

urinary  tract  is  very  difficult  and  complicated,  no  matter  complicated 
what  the  cause  of  the  pathological  process,  may  be.  We  all  thatltu**' 
know  how  prone  to  chronicity  is  any  condition  arising  in  easily  sus- 

1        -i  •  n  '  -i  e  .'•*'•  ceptible  to 

the  kidney  or  in  any  other  part  01  the  genito-urinary  tract,  permanent 
When  a  posterior  urethritis  remains  for  years,  it  is  not  damage- 
because  the  infection  with  the  gonococcus  differs  from  the 
infection  with  any  other  organism,  for,  when  the  colon  bacil- 
lus produces  a  pathological  process  in  the  pelvis  of  the 
kidney,  it  is  equally  tenacious.  Even  the  non-infectious 
diseases  attacking  the  kidney  leave  permanent  damage  be- 
hind. We  need  only  recall  nephritis  complicating  scarlet 
fever,  or  diseases  causing  an  interstitial  connective  tissue 
change  as  in  an  interstitial  nephritis,  to  realize  how  sus- 
ceptible to  damage  the  kidneys  are.  It  is  the  complicated 
mechanism  of  the  genito-urinary  tract  that  renders  it  vul- 
nerable, not  the  nature  of  the  process  attacking  it.  Hence, 
permanent  damage  depends  less  upon  the  virulence  of  the 
process  than  upon  the  Jength  of  time  such  process  is  allowed 
to  go  on  without  being  checked. 

It  therefore  follows  that  in  renal  tuberculosis,  the  proper 
treatment  must  be  instituted  as  early  as  possible  and  that 
many  symptoms  persisting  beyond  such  treatment  are  due 
to  the  permanent  damage  done  before  treatment  rather  than 
to  the  persistence  in  spite  of  the  treatment  of  the  original 
pathological  process. 

The  early  treatment  of  renal  tuberculosis  naturally  de- 
pends upon  the  early  diagnosis  of  the  condition.  But  just 
here  the  greatest  difficulty  arises.  Early  tubercular  pro- 
cesses are  usually  circumscribed,  very  slow  in  progress,  and 
thus  exercise  very  little  influence  upon  the  function  of  the 
kidney.  The  patients  at  this  time  are  usually  in  robust  health 
7 


1)8 


TUBKKCULIN    AND    VACCINE 


To  obtain 
ideal  results 
with  tuberculin 
it  must  be 
applied  before 
permanent 
damage  has 
resulted. 


But  just  here 
we  meet  with 
the  greatest 
difficulty,  as 
an  early 
diagnosis  is 
rarely  made. 


and  merely  go  to  the  family  physician  complaining  of  an 
annoyance,  which  usually  consists  of  frequent  micturation, 
especially  at  night.  The  possibility  of  a  tubercular  affection 
in  the  kidney  is  remote  from  the  physician's  mind.  Every 
conceivable  condition  that  might  occur  in  the  bladder,  urethra 
or  prostate  is  suspected,  and  the  patient  treated  for  it.  If, 
for  instance,  the  male  patient  gives  a  history  of  a  gonorrheal 
urethritis,  then,  of  course,  the  symptoms  are  easily  explained 
on  those  grounds  and  the  patient  is  subjected-  to  all  sorts 
of  instrumentation  and  treatment.  With  the  progress  of 
the  disease,  the  diagnosis  of  cystitis  is  made  and  is  followed 
by  irrigation  of  the  bladder,  prostatic  massage  (encouraging 
an  active  lesion  in  the  prostate  if  a  tubercular  infection  has 
reached  it)  and  various  other  means  directed,  against  a  sup- 
posed gonorrheal  infection.  When  the  process  is  still  fur- 
ther advanced,  the  symptoms  referable  to  the  kidneys  begin 
to  be  more  pronounced;  pus  in  the  urine,  perhaps  blood  in 
the  urine,  backache  radiating  toward  the  pelvis;  all  these 
symptoms  bring  the  diagnosis  of  renal  calculus,  and  in  the 
female  many  pelvic  (disorders  are  suspected.  Finally,  the 
diagnosis  of  renal  tuberculosis  is  made,  sometimes  by  a 
careful  study  of  the  patient  through  expert  assistance,  some- 
times by  chance  as  in  the  case  mentioned  in  connection  with 
mixed  infection  (page  163),  where  the  diagnosis  of  tuber- 
culosis was  made  upon  the  discovery  of  tubercle  bacilli  in 
the  thick  pus,  which  took  the  place  of  urine.  Occasionally, 
the  X-ray  finds  an  enlarged  kidney  without  calculus  and 
raises  the  suspicion  of  tuberculosis. 

To  sum  up?  the  diagnosis  of  renal  tuberculosis  always 
conies  too  late  for  the  institution  of  early  treatment  prin- 
cipally for  the  reason  that  the  usual  methods  for  making 
a  diagnosis  are  complicated  and  generally  require  a  spe- 
cialist. The  result  is  that  the  general  practitioner  tries  all 
available  treatment  for  any  other  possible  disease  until  he 
finds  his  treatment  hopeless  and  refers  the  patients  for 
expert  advice.  The  diagnosis  of  renal  tuberculosis  by  means 


REXAL  TUBERCULOSIS  99 

of  tuberculin  -is  bu  far  the  best  at  our  disposal,  for  it  is  the  w'ththe 

subcutaneous 

only   means  for  early   diagnosis.      ^Yith   tuberculin,    diag-  tuberculin  test 

.    .  an  early 

nosis  can  be  resorted  to  by  every  physician  and  in  every  diagnosis  is 
locality.    The  interpretation  of  the  positive  finding  is  simple  ne^oni  to 
in  the  case  of  renal  tuberculosis  and  if  the  multiple  method  be  properly 

applied  and 

of  tuberculin  inoculation  is  practiced  (see  page  23),  it  is  correctly 
devoid  of  danger.  Frequent  micturation  in  an  otherwise  interPreted- 
healthy  individual  should  always  be  the  subject  of  sus- 
picion and  a  tuberculin  test  resorted  to  at  once.  If  the 
case  is  not  tubercular,  the  tuberculin  will  do  no  harm.  If 
the  case  is  tubercular,  the  harm  done  by  a  constitutional 
reaction,  even  if  severe,  can  not  be  considered  in  compari- 
son to  the  harm  that  comes  to  the  patient  from  long  delayed 
diagnosis  and  from  instrumentation,  bladder  irrigation  and 
other  treatments  that  are  resorted  to,  previous  to  the  diagno- 
sis, either  for  the  treatment  of  supposed  conditions,  or  for  the 
diagnosis  itself.  It  is  quite  true  that  were  we  to  suspect 
a  tubercular  condition  in  every  case  where  a  definite  diag- 
nosis cannot  be  established,  and  where  the  patient  com- 
plained of  frequent  micturation,  the  vast  majority  of 
patients  will  prove  negative  to  the  tuberculin  test.  I  have 
never  yet  found  a  patient  resenting  the  test  when  it  proved 
negative  and  when  it  was  explained  that  through  the  test 
we  have  excluded  even  the  remotest  possibility  of  an  active 
tubercular  affection.  On  the  contrary,  the  patient  is  grate- 
ful to  the  physician  for  his  endeavor  to  establish  an  early 
diagnosis  of  a  suspected  condition. 

With    an    early    diagnosis    established,    how    shall    we  Onceanear/y 
proceed  with  the  treatment?     I  do  not  know  of  any  one  diagnosis  is 

,  .  .   ,  made,  no 

who    would    advocate   the   removal    of   a    kidney    with    an  other  remedy 
earlv    lesion.      There    remains    onlv    the    hvgienic-dietetic-  ca"Prove. 

«•'  « e  effective  in 

and-climatic    treatment    to    be    instituted    for    the    patient   limiting  the 
when  an  early  diagnosis  is  made.     And  what  can  that  offer  we°iieasss 
us?     Unlike  the  patients  with  pulmonary  tuberculosis,  this  ^e^urce* 
class  of  patients  are  in  fine  physical  condition,   and  if  a  of  infection 
fine   physical   condition   did  not   prevent   the   lesion   from  tuberculin. 


100  TUBERCULIN  AND  VACCINE 

starting  in  the  kidney,  how  can  we  expect  treatment  which 
depends  upon  the  improvement  of  the  physical  condition,  to 
cure  or  even  check  the  disease  ?  Here  we  deal  with  a  com- 
bination of  circumstances  all  of  which  are  already  favorable 
to  the  production  of  a  natural  immune  response  against  the 
tubercle  bacilli,  except  that  the  mechanism  producing  the 
immune  response  is  faulty.  The  stimulation  of  this  mechan- 
ism with  tuberculin  remains  the  only  logical  early  treat- 
ment. All  other  resources  necessary  for  the  patient's  own 
defense  are  present  in  sufficient  quality  and  quantity. 
By  the  time  When  once  a  diagnosis  is  possible  without  tuberculin, 

the  patient  presents  a  picture  of  chronic  inflammation  that 


made  under 


ordinary  T1O  Other  chronic  condition  presents.     Especially  is  this  true 

methods,  .  f  . 

permanent  in  the  male  patient.     He  is  never  free  from  pain  and  dis- 

ah-T^dy  a  comfort,  cannot  have  a  peaceful  night's  sleep  on  account  of 

the  necessity  of  frequent  urination,  often  cannot  do  without 
a  permanent  urinal,  because  of  incontinence;  cannot  take 
a  ride  in  any  vehicle  because  the  jars  cause  agonizing  pains ; 
in  short,  the  advanced  renal  case  is  subject  to  every  con- 
ceivable discomfort  that  makes  life  unbearable.  Most  of 
these  symptoms  come  from  the  extension  of  the  disease  into 
the  bladder,  the  prostate  and  the  urethra.  A  great  many 
small  ulcerations  which  have  been  produced  traumatically 
by  instrumentation  form  the  seat  for  new  tubercular 
infection.  Although  no  one  but  the  skilled  specialist 
should  resort  to  cystoscopy  and  ureteral  catheterization,  they 
are  nevertheless  far  too  frequently  resorted  to.  Many  of 
these  instrumental  examinations  are  made  in  spite  of  the 
knowledge  that  they  could  in  no  way  improve  the  condition 
of  the  patient,  but  which,  on  the  contrary,  may  aggravate 
the  condition  temporarily  or  even  permanently. 

In  the  exclusive  interest  of  the  patient,  what  would 
seem  to  offer  the  best  procedure  in  the  treatment  of  renal 
tuberculosis  in  the  state  in  which  it  is  discovered  in  the 
majority  of  instances?  It  is  quite  true  that  a  removal  of 
a  kidney  has  occasionally  cured  a  case  of  renal  tuberculosis, 


TUBERCULOSIS  101 

even  with  ulcerations  of  the  bladder.  I  am  quite  certain 
that  in  these  instances  a  closer  analysis  would  reveal  that 
the  principal  cause  of  the  patient's  condition  at  the  time 
of  operation  lay  elsewhere  than  in  the  tubercular  infection. 
For  example:  In  a  case  of  renal  tuberculosis  where  the 
tubercular  infection  is  more  or  less  spent,  but  where  the 
ulcerations  in  the  bladder  and  the  predominating  patho- 
logical processes  in  the  kidney  are  due  to  mixed  infection, 
the  kidney  will  act  as  a  foreign  body.  The  stroma  is 
entirely  destroyed  iby  multiple  abscesses  so  that  the  re- 
moval of  the  kidney  is  sufficient  to  cure  the  patient.  Again 
in  a  case  of  calculus  with  accompanying  hematuria  or 
pyelitis  producing  the  predominant  symptoms  but  where 
a  small  quiescent  tubercular  lesion  exists,  the  removal  of 
such  a  kidney  will  result  in  a  complete  cure.  This  is  ana- 
logous to  the  condition  that  exists  in  bone  and  joint  disease 
where  the  tubercular  infection  has  healed  and  the  sinuses 
are  kept  open  by  mixed  infection  or  irritating  accumulations, 
the  removal  of  which  by  bismuth  paste  is  sufficient  to  com- 
plete the  cure. 

On  the  other  hand,  in  the  majority  of  cases  where  the  The  removal 
principal  cause  of  all  the  symptoms  is  a  slowly  progressive  °s  inmost™ 
tubercular  infection,  how  can  we  expect  to  cure  the  patient  instancesan 

attempt  to 

with  the  extirpation  of  one  kidney  ?     Not  only  do  we  leave  remove  a  local 
behind  a  tubercular  process  in  the  urinary  tract  below  the  constitutional 
removed  kidney,  but  with  the  added  burden  suddenly  thrown  disease- 
upon  the  remaining  kidney,  its  resistance  may  be  momen- 
tarily lowered  and  it  may  become  infected  from  the  original 
focus.     The  hypersusceptibility  being  increased  as  a  result 
of  the  operation,  will  more  than  encourage  this  occurrence 
and  bring  about  a  most  hopeless  condition. 

General  Hypersusceptibility 

The  general  hypersusceptibility  in  renal  tuberculosis  is 
on  a  par  with  the  general  hypersusceptibility  in  closed  glands 
so  long  as  the  infection-  is  limited  to  the  lesion  in  the  kidney. 


102  TUBERCULIN  AND  VACCINE 

The  general         That  [s    ft  is  not  of  a  very  high  degree  and  would  require 

hypersus-  „ 

ceptibiiity  in       about  0.10  c.c.  of  the  second  dilution  to  cause  a  reaction. 
There  are,  of  course,  a  great  many  exceptions,  such  as  the 


tuberculosis 
is  of  a  1 
degree. 


hypersuscep'tibility  in  early  cases  of  renal  tuberculosis  fol- 


lowing an  infectious  disease  or  in  oases  where  the  focus  of 
the  infection  is  active,  in  which  instance  we  would  consider 
the  hypersusceptibility  due  to  that  focus  and  not  to  the 
lesion  in  the  kidney. 

In  later  cases,  there  are  two  (distinct  grades  of  hyper- 

susceptibility.     On  the  one  hand  there  is  the  class  of  cases 

with  extensive  ulcerations  of  the  kidney,  with  complicated 

The  general         bladder  ulcerations.     In  these  cases  the  lesion  is  active,  the 

ceptTbufty  in       susceptibility  is  extremely  high  and  occasionally  will  require 

advanced  cases     a  sixth  dilution  for  the  beginning  of  treatment  in  order  to 

is  of  two 

distinct  grades:  avoid  reaction.  On  the  other  hand,  we  have  renal  tuber- 
wVere  'there  culosis  consisting  of  calicies,  which  are  converted  into  sacks 
is  an  active  Of  cheesy  material  or  cold  abscesses.  Here  the  entire  kidney 

ulcerative  *  ..." 

process  in  acts  as  a  foreign  body,  its  function  being  entirely  destroyed. 

and  Madder.        ^  ^s  apt  to  have  ,very  little  active  tubercular  inflammation 


it  is  low  in          jn  j^     TI^  tubercle  bacilli  that  are  still  found  in  the  urine 

cheesy  or 

fibrous  kid-         are  of  a  fungoid  character,  while  the  ulceration  in  the  blad- 


"hep'roceYs"         c^er  an^  elsewhere  is  continued  merely  by  the  presence  of 
is  continued        the  acjd  urine  and  mixed  infections.     In  such  a  condition, 

by  mixed 

infection  and       the  patient  is  apt  to  be  in  good  physical  condition  with  very 
baciin.  "  little  loss  of  weight,  in  spite  of  the  ever-present  extreme  dis- 

comforts. The  susceptibility  in  these  cases  is  very  low  and 
occasionally  does  not  exist  at  all.  The  latter  is  the  condition 
in  which  the  removal  of  the  kidney  without  any  other 
treatment  [very  frequently  cures  the  patient. 

The  presence  of  hypersusceptibility  in  various  degrees 
and  its  absence  altogether  in  renal  tuberculosis  may  be  of 
service  to  the  surgeon  in  determining  upon  a  nephrectomy. 
For  instance,  if  with  a  tuberculin  test  a  considerable  degree 
of  hypersusceptibility  is  discovered,  before  a  contemplated 
operation,  it  may  serve  as  a  warning  against  it  and  a  course 
of  tuberculin  inoculations  should  be'  given  instead,  or  pre- 


RENAL  TUBERCULOSIS  103 

paratory  to  the  operation.     On  the  other  hand,  if  the  hyper-  The  tuberculin 
susceptibility  does  not  exist  at  all,  or  only  to  a  very  mild  guide  to 
degree,  it  is  sufficient  evidence  that  the  tubercular  infection  -interference, 
has  subsided  and  that  the  condition  in  the  kidney  and  else- 
where is  merely  the  result  of  the  tubercular  infection.     Then 
surgical  interference  can  be  instituted  with  a  fair  degree  of 
safety,  and  a  reasonable  amount  of  success  may  be  expected. 

Beginning  Treatment 

In  early  cases  of  renal  tuberculosis,  it  is  quite  safe  to 
begin  treatment  with  the  fourth  dilution,  and  when  it  re- 
quired the  second  dilution  to  cause  a  reaction  during  a  test, 
it  is  safe  to  begin  the  treatment  with  the  third  dilution. 
In   more   advanced  cases  our  judgment   as   to  the  amount 
of  tuberculin  in  the  beginning  of  treatment  must  be  influ-  The  beginning 
enced  by  the  nature  of  the  symptoms  at  hand.     Thus,  if  the  tuberculin™1 
patient  runs  an  abnormal  temperature,  for  which  no  other  should  wait 

'  until  an 

cause  can  be  found  than  the  tubercular  process,  the  fifth  acute  mixed 
dilution  is  indicated  for  the  beginning  of  the  treatment.  ^  controlled. 
That  is  also  true  in  a  case  of  persistent  hemorrhage.     How- 
ever, if  the  severer  symptoms  are  caused  by  other  conditions 
than  the  tubercular  process  —  conditions  such  as  calculus, 
mixed  infection,  pyelitis,  etc.  —  tuberculin  treatment  can  be 
instituted  with  the  fourth  dilution.     It  is,  however,  better 
to  treat  the  mixed  infection  until  the  temperature  is  normal 
(see  page  175)  before  tuberculin  treatment  is  commenced. 

Conclusion  of  Treatment 

The  conclusion  of  treatment  as  far  as  tuberculin  is  con-  in  most  cases 
cerned  is  more  like  that  in  a  case  of  pulmonary  tuberculosis 


with   <?avitv   formation   than   in   a    purelv   glandular   type.  is  best 

.  .,.  t         t  •     i  <•-!•  accomplished 

It  is  best  —  as  is  advised  in  the  third  section  ot  this  work  —  by  the  slow 

to  spread  the  conclusion  over  as  long  a  period  as  it  takes  BEmethod- 
to  treat  the  patient  for  the  complications.     Once  the  B.E. 
is  reached,  the  increase  of  the  dose  can  be  made  regularly 


104  TUBERCULIN  AND  VACCINE 

by  0.05  c.c.  and  continued  until  0.30  c.c.  or  even  0.040 
c.c  of  pure  B.E.  is  reached.  It  will  thus  take  25  to  30 
inoculations  given  at  weekly  intervals  while  administering 
the  B.E.I,  and  ten-day  to  two-  weekly  intervals  when  ad- 
ministering the  pure  B.E.  This  will  carry  the  conclu- 
sion of  treatment  over  a  period  of  -a  year,  allowing  ample 
time  for  any  other  treatment  that  may  be  necessary.  It 
is  especially  advisable  to  continue  the  treatment  during 
the  convalescence  from  a  nephrectomy  and  for  some  time 
after.  Of  course,  if  a  nephrectomy  can  be  postponed  until 
after  all  the  B.E.  inoculations  have  been  given,  it  would  be 
to  the  advantage  of  the  patient  ;  but,  if  the  condition  of  the 
kidney  is  guch  as  to  require  the  operation  at  the  earliest 
possible  moment,  it  may  be  performed  after  the  conclusion 
of  the  OT  administration. 

In  incipient  cases  of  renal  tuberculosis,  such  as  are  dis- 
in  tuberculin       covered  through  the  tuberculin  test,  the  conclusion  of  treat- 
ment  is  very  simple.     The  process  is  limited  to  a  small, 


conclusion          usually  circumscribed,  area  in  the  kidney,  and  is  not  unlike 

is  simple.  . 

the  process  in  closed  glands.  After  the  usual  conclusion 
with  OT  the  short  course  of  BE  is  administered,  followed 
for  two  years  by  the  tri-monthly  test. 


CHAPTER  VI 


I  have  no  doubt  conveyed  the  idea  that  most  phases  of  Tuberculin 

tuberculosis  have  been  neglected   from  the  standpoint   of  more  widely 

immuno-therapy.      This   statement,   (however,   does  !not  by  p^^nary 

any  means  apply  to  pulmonary  tuberculosis.     This  form  of  tuberculosis 

i'-r'  ,  .  .-,  f        •  than  in  any 

tuberculosis,  I  must  admit,  has  been  given  its  share  of  scien-  other  form  of 
tific  labor.     I  need  but  refer  the  reader  to  the  exhaustive  t! 
literature  on  the  subject  and  he  could  spend  the  remainder 
of  his  natural  life  perusing  it. 

Tuberculin   has  been   used  in  pulmonary  tuberculosis  The  literature 
more  extensively  than  in  any  other  form  of  tuberculosis  and  however, 
the  results  of  its  use  have  been  published  in  nearly  every       "°ut  the 


country.     However,  one  cannot  help  but.  gain  the  impres-  tuberculin 
sion  from  reading  these  reports  that  tuberculin  has  been  applied  mainly 


as  a  last  resort 


applied  as  a  last  resort  measure,  and  that  the  incipient  case 

measure. 

has  been  considered  easy  of  cure  either  through  climate, 
sanatorium  treatment,  or  rest  and  hyperalimentation  ;  in 
short,  the  hygienic-dietetic-and-climatic  treatment  is  alone 
in  consideration  and  tuberculin  is  used  only  when  this 
method  produces  no  results. 

In  Germany,  however,  the  value  of  tuberculin  in  early 
cases  of  pulmonary  tuberculosis  has  been  recognized  and  its 
increased  use  there,  in  the  last  decade,  has  evinced  a  marked 
diminution  in  the  death  rate  from  pulmonary  tuberculosis. 
So  marked  has  this  reduction  in  the  death  rate  been,  that 
the  public  demand  for  sanatoriums  where  tuberculin  is 
administered  has  become  quite  general;  and  as  a  result, 
ninety  per  cent,  of  all  institutions  in  Germany  where  pi-1- 
monary  tuberculosis  is  being  treated  are  now  using  tuber- 
culin together  with  the  hygienic-dietetic  measures. 

The  actual  origin  of  the  public  education  in  Germany 
regarding  the  use  of  tuberculin  is  the  accurate  statistics  kept 


100  TUBERCULIN  AND  VACCINE 

The  uck  cf  by  the  German  Government.  In  this  country  statistical 
Sic"  hi*"  reports  of  disease  and  the  causes  of  death  are  in  such  a 
prevented  deplorable  state  that  the  public  is  not  in  a  position  to  com- 

a  public  * 

demand  for  pare  the  results  obtained  by  the  use  of  tuberculin  in  one 
community  with  the  results  obtained  without  its  use  in 
another  community.  It  is,  therefore,  useless  for  the  medical 
profession  in  this  country  to  await  the  public  demand  for 
tuberculin.  On  the  contrary,  it  remains  for  the  general 
practitioner  to  wake  up  to  the  truth  as  shown  by  the  records 
supplied  by  Germany,  and  help  educate  the  public  to  its 
advantages. 

Through   innumerable  autopsies  in  every  part  of  the 
world,  on  subjects  having  died  from  other  diseases  than  tuber- 

xhe  human          culosis,  and  through  thousands  of  autopsies  made  upon  sub- 
having  died  through  accident  in  apparently  perfect 


S! 


immunity  health,  it  has  been  established  that  tuberculosis  is  a  universal 

against 

tuberculosis.  disease.  In  fact,.  from  most  conservative  sources,  we  gather 
that  hardly  twenty  per  cent,  of  the  human  race  escape  a 
lesion  in  the  lung,  and  yet  the  percentage  of  deaths  due  to 
pulmonary  tuberculosis  is  hardly  one-tenth  of  that  number. 
Thus,  a  fact  which  must  remain  undisputed  is  brought  home 
to  every  one  of  us  ;  that  the  human  race  possesses  a  natural 
immunity  against  tuberculosis. 

The  sole  cause,  then,  for  the  morbidity  of  the  disease  is 

the  falling  short  of  the  amount  of  natural  immunity  neces- 

Thosewho  sary  to  check  it.     It  is  a  very  small  minority  of  cases  that 

t'hed^eas'e          possess  no  immunity  or  so  very  little  that  they  succumb  to 

lack  sufficient       the  hasty  form  of  tuberculosis.     In  fact,  we  can,  with  cer- 

immune  .  * 

response  tainty,  deduce  that  the  mechanism  of  active  immunization 

mflcte"1  pkys  a  role  in  nearly  every  case  of  pulmonary  tuberculosis 

in  its  incipiency  —  acting  for  a  longer  or  for  a  shorter  time 
as  the  case  may  be  —  and  finally  wearing  itself  out  until  the 
disease  spreads  and  causes  death.  Very  little  stimulation 
of  the  protective  mechanism  would  have  been  required  to 
turn  the  balance  in  favor  of  these  victims. 

Immuno-therapy  alone  could  have  supplied  this  stimu- 


PULMONARY  TUBERCULOSIS  107 

lation  and  it  remains  clear  that  such  a  stimulation  if  sup- 
plied early,  would  prove  more  effective  and  would  leave  less 
permanent  damage  in  the  lungs  than  if  applied  late  in  the 
disease.  The  question,  however,  that  would  arise  is :  How 
are  we  to  judge,  in  early  cases,  those  that  possess  the  neces- 
sary amount  of  natural  immunity  and  those  that  fall  short 
of  it?  Would  we  not  be  apt  to  treat  a  great  many  cases 
with  tuberculin  that  might  have  gotten  well  without  it? 
These  questions  can  be  very  easily  answered  if  we  recall 
how  large  is  the  number  of  cases  of  incipient  pulmonary 
tuberculosis  that  come  quite  early  in  the  disease,  and  in  spite 
of  the  best  in  the  way  of  hygienic-dietetic-and-climatic  treat- 
ment, progress  unfavorably.  The  careful  treatment  with 
tuberculin  would  do  no  harm  to  those  who  would  have  got- 
ten well  without  it ;  on  the  contrary,  it  would  fortify  them 
against  a  recurrence,  and  at  the  same  time  would  be  the  An  artificial 

f  ,  ••         i .  ,.  i         i       -i     •          cr>    •       L    stimulation  of 

means  01   saving  the  lives  01  many  who  had   insufficient  the  immune 
immune  response  to  begin  with.     By  way  of  illustration,  «sp°nse  is 
I  shall  mention  one  recent  report.    It  came  from  the  Loomis  most  rational 
Sanitarium    and    was    made    by    Doctor    H.  ,  M.    King,  an^t""4 
The  report  showed  that  in  spite  of  sanitarium  treatment  earlierinth« 

disease  it  is 

under  the  best  posible  conditions,  over  twenty-nine  per  cent,  applied  the 
of  the  incipient  cases  treated  at  that  sanitarium  died  of  a  response,  and 
recurrence  of  their  disease  within  ten  years  after  discharge.  the  less 

permanent 

Many  such  reports  can  be  found  throughout  the  literature;  damage 
very  few,  however,  could  show  even  such  favorable  results. 
In  contrast,  if  we  examine  into  the  results  of  immuno- 
therapy  in  incipient  cases  of  tuberculosis  reported,  we 
shall  find  that  the  percentage  of  permanent  cures  runs  close 
to  one  hundred  per  cent.,  and  this  from  unquestionable 
authority.  The  difference  can  easily  be  explained:  the 
hygienic-dietetic  measure  is  one  that  aims  to  strengthen  the 
individual  as  a  whole  with  the  hope  that  it  will  also  increase 
his  natural  defense  against  tuberculosis  as  an  infection. 
In  a  large  number  of  incipient  cases — nearly  seventy  per 
cent. — it  succeeds.  But  even  in  these  the  hypersuscepti- 


108 


TUBERCULIN  AND  VACCINE 


The  artificial 
stimulation 
of  the  immune 
response  does 
not  interfere 
with  the 
natural  immune 
response. 


There  are  no 
real  contra- 
indications 
to  the  use  of 
tuberculin. 


Fever  may  be 
a  temporary 
contra- 
indication 
when  caused 
by  mixed 
infection. 


bility  remains;  and,  while  in  the  thirty  per  cent,  of  fatal 
cases  it  was  the  means  of  an  early  recurrence  and  death,  in 
the  favorable  cases  it  still  remains  a  menace — even  beyond 
ten  years. 

The  artificial  stimulation  of  the  immune  response  can- 
not interfere  with  the  natural  immune  response.  That  is 
beyond  question.  Where,  then,  is  the  objection  to  the  use 
of  tuberculin  in  such  cases  that  would  have  gotten  well  on 
the  hygienic-dietetic  treatment  alone  ?  •  The  only  danger  lies 
in  the  too  frequent  and  in  the  severe  reactions  caused  by 
a  faulty  technique.  The  fault,  therefore,  is  not  in  the 
tuberculin  itself,  but  in  its  method  of  use,  and  once  we  have 
established  a  method  of  administration  which  avoids  severe 
and  frequent  reactions,  the  objection  to  tuberculin,  per  se, 
can  no  longer  be  advanced  as  a  justification  for  its  neglect. 

Centra-indications 

From  the  outset  I  want  to  be  understood  as  denying  the 
existence  of  contra-indications.  I  do  not  believe  that  real, 
genuine  contra-indications  to  the  use  of  tuberculin  exist. 
The  harmful  results  recorded  were  not  obtained  by  the  use 
of  tuberculin  under  the  wrong  conditions,  but  from  the  wrong 
method  of  use  of  tuberculin;  ;and  the  failure  to  recognize 
this  fact  has  produced  a  long  list  of  "  contra-indications." 
Were  we  to  take  a  census  of  the  conditions  put  forth  by 
different  investigators  as  '"  contra-indications "  to  the  use 
of  tuberculin  and  take  them  all  seriously,  there  would  be 
very  few  cases  left  for  tuberculin  therapy.  For  instance: 

FEVER  is  maintained  to  be  a  most  constant  contra-indi- 
cation  in  spite  of  the  fact  that  it  is  very  frequently  a  symp- 
tom of  incipient  tuberculosis  where  tuberculin  has  its  most 
effective  field.  However,  as  mentioned  above,  fever  may  be 
produced  by  mixed  infection.  The  failure  to  differentiate 
between  this  fever  and  that  produced  by  the  tubercular  infec- 
tion has  occasionally  led  to  an  improper  application  of  the 
tuberculin  treatment,  producing  harmful  results  in  cases  of 


PULMONARY  TUBERCULOSIS  109 

fever.  There  is  no  antipyretic  as  effectual  as  tuberculin  in 
tubercular  fever.  The  fever  produced  by  mixed  infection 
should  not  exclude  the  use  of  tuberculin  altogether ;  it  should 
postpone  its  use  until  the  mixed  infection  has  been  cleared 
to  the  extent  of  reducing  the  temperature.  However,  if  the 
mixed  infection  resists  all  treatment,  and  the  fever  which  it  . 
causes  continues  ithe  wasting  of  the  patient,  tuberculin  will 
have  no  effect.  1 

DEBILITY.       Debility    is    another    "  centra-indication " 
very  frequently  mentioned.     As  stated  above,   the  loss  of 
reactive  properties  on  the  part  of  the  patient  forms  a  natural  Debility  is  a 
limitation  and  not  a  centra-indication  to  the  use  of  tuber-  limitation 
culin.      It    is    true   that    the    use    of    tuberculin    in    cases  Indication*" 
suffering  from  debility  will  produce  absolutely  no  results, 
but  neither  will  it  cause  any  harm.     And  since  we  cannot 
determine  absolutely,  until  the  tuberculin  has  been  tried, 
whether  or  not  the  reactive  properties  of  an  individual  are 
lost,  the  use  of  [tuberculin  will  occasionally  meet  with  a  re- 
sponse where  the  symptoms  of  debility  were  pronounced. 
Thus,  by  excluding  tuberculin  from  a  whole  class  of  cases,  we 
might  omit  the  use  of  tuberculin  where  it  would  prove  of 
inestimable  value. 

True,  the  number  of  such  cases  is  very  small,  but  it  is  Theuseof 

tuberculin  is 

also  true  that  trying  tuberculin  for  a  short  time  in  cases  justifiable  in 
where  the  immune  response  has  been  exhausted  will  pro-  ^ It  can  pro-  '* 
duce  no  harm,  as  a  reaction  cannot  occur.     In  the  practice  ducenoharm. 
of  medicine,  it  is  axiomatic  that  the  use  of  a  remedy  •  is* 
justifiable  in  many  cases  where  it  produces  no  beneficial 
results,   but  proves  harmless — so  long  as  that  remedy  is 
efficient  in  the  salvation  of  the  few. 

That  tuberculin  might  awaken  an  immune  response  is  Tuberculin 

"•',  *   :       i         •  11-      may  awakcn 

particularly  true  in   those  cases  of  cachectic   tuberculosis  a  response  in 

with  only  small  areas  of  lung  involvement.     We  know  that 

the  effect  of  tuberculin  on  the  blood  is  distinctly  stimulat-  « 

ing,  both  the  red  and  the  white  blood  cells  increase  far  thought  to 

more  rapidly  than  through  any  other  form  of  treatment 


110  TUBERCULIN  AND  VACCINE 

Classification 

The  classification  of  pulmonary   tuberculosis  is  by  no 

means  an  easy  matter  and  it  is  not  surprising  that  almost 

i.  incipient.         as  .many  varieties  of  classifications  exist  as  there  are  writers 

siowiy™  on  the  subject.    The  structure  of  the  lung  tissue,  the  variety 

Progressive:        jn  tne  pathological  process,  to  which  added  the  great  dif- 

(a)  fibrous  .  . 

phthisis;  ference  in  individual  susceptibility  and  resistance  to  the 

indukerl'ti've3  tubercle  bacilli,  all  taken  together  tend  to  make  for  not  only 

3  Acute  or  a  variety  in  the  gross  pathological  difference,  but  also  in 

(a)  febrile;  the  symptoms  which  they  bring  about.    Fortunately,  the  task 

(infeTtiond  is  not  quite  so  difficult  for  the  immunizator.     In  dealing 

(2)  auto-  wjtjj  tjle  imimme  response,  we  need  take  cognizance  of  the 

inoculation; 

(b)a{ebriie;        pathological  difference  in  the  lungs  of  different  individuals 
rhag'cT  011lv  in  as  far  as  tneJ  produce  a  difference  in  symptoms  and 

en  traumatic,     tjiat  on]v  jn  a  p-eneral  wav.     As  far  as  tuberculin  therapy 

(2)  ulcerative. 

is  concerned,  only  such  differences  can  have  any  bearing 
upon  it.  as  the  presence  or  absence  of  hemorrhage,  or  the 
chronicity  or  the  rapidity  of  the  process  involved.  This 
classification  therefore  will  depend  entirely  upon  its  refer- 
ence to  tuberculin  therapy  and  if  it  differs  materially 
from  the  usual  classifications  bearing  on  the  stages  of  the 
disease,  etc.,  it  will  find  its  justification  in  the  fact  that 
this  classification  is  merely  made  to  add  to  the  simplicity 
of  the  tuberculin  therapy.  Accordingly,  the  tubercular  pro- 
cesses in  the  lung  are  divided  into  'the  following  three  groups : 

1.  THE  INCIPIENT  PULMONARY  TUBERCULOSIS.     Under 
this  group  only  such  cases  are  considered  which  require  a 
test  to  establish  a  diagnosis  and  which  show  physical  signs 
before  the  presence  of  tubercle  bacilli  in  the  sputum. 

2.  TlIE    CHRONIC    OR    SLOWLY    PROGRESSIVE    PULMONARY 

TUBERCULOSIS.  Under  this  group  are  included  the  type  of 
cases  which  persist  for  a  long  time,  the  natural  resistance 
being  sufficient  to  prevent  an  acute  attack,  but  not  quite 
sufficient  to  arrest  the  process;  also  those  cases  in  which  the 
process  has  been  arrested  one  or  more  times  with  the  light- 


PULMONARY  TUBERCULOSIS  111 

ing  up  of  the  infection  under  a  change  of  conditions  whether 
extrinsic  or  intrinsic.  All  patients  with  tubercle  bacilli  in 
the  sputum  are  here  included,  embracing  all  cases,  from  local- 
ized infiltrations  in  the  lung  to  those  that  have  progressed  for 
several  years,  and  are  now  suffering  from  ulceration  and 
cavity  formation  or  calcification.  For  the  purpose  of  greater 
simplicity,  this  group  is  subdivided  into  two  types. 

(a)  Those  with  extensive  infiltration,  connective  tissue 
change  or  fibrous  phthisis. 

(b)  Those  with  calcification  process,  the  calcarious  de- 
posit finally  causing  ulcerations  and  cavity  formation.     We 
shall  not  discuss  here  whether  the  action  of  the  calcarious 
deposit  as  a  foreign  body  is  brought  about  by  mixed  infec- 
tion or  by  the  tubercular  process,  as  this  question  has  no 
bearing  upon  tuberculin  therapy.     But  the  decision  as  to 
whether  there  is  a  fibrous  phthisis  or  cavity  formation  will 
have  a  great  bearing  upon  the  conclusion  of  treatment  as 
will  be  indicated  further. 

3.  ACUTE  OR  ACTIVE  PULMONARY  TUBERCULOSIS.  Here 
we  shall  include  the  more  active  form  of  tuberculosis,  the 
kind  that  progresses  rapidly  either  through  lack  of  the 
immune  response  or  through  an  over  stimulation  of  the 
mechanism  of  immunity  .by  auto-inoculation,  or  through  a 
rapid  loss  of  strength,  due  to  an  excessive  loss  of  blood.  In 
this  group  belong  the  greater  number  of  patients  who  are 
considered  as  disqualified  for  tuberculin  therapy,  and  at 
the  same  time  stand  particularly  in  need  of  something  more 
than  the  present  day  treatment  to  turn  the  tide  in  their 
favor.  By  a  closer  analysis  we  are  isure  to  be  able  to  find 
a  considerable  number  of  those  considered  hopeless  that  may 
be  rescued  with  tuberculin.  With  a  safer  technique,  'any 
harm  that  might  be  caused  by  tuberculin  is  so  slight  and  so 
infrequent  that  the  good  its  general  use  can  accomplish  in 
saving  the  victims  of  this  disease  will  far  outbalance  any 
possible  harm.  Thus,  we  shall  find  that  an  active  condition 
and  pyrexia  are  brought  about  not  so  much  by  an  uncon- 


112 


TUBERCULIN  AND  VACCINE 


The  structure 
of  pulmonary 
tissue,  with 
its  rich 
blood  supply 
encourages 
autoinoculation 
which  increases 
the  hypersus- 
ceptibility. 


trolled  tubercular  process  as  by  a  mixed  infection,  and  if 
we  were  to  take  fever  as  a  general  centra-indication  we 
would  lose  a  large  number  of  cases  that  come  under  this 
class.  A  subdivision  of  this  class  into  febrile,  afebrile  and 
hemorrhagic  cases,  enables  us  tv  further  simplify  treatment. 
For  example,  in  taking  up  the  first  of  these  three,  we  must 
endeavor  to  analyze  the  cause  of  the  fever  and  determine 
whether  it  is  due  to  autoinoculation  or  to  mixed  infection. 
In  the  active  afebrile  group  where  the  rapidity  of  the  process 
is  causing  ulceration,  the  ,sole  cause  may  be  an  insufficient 
immune  response.  Under  the  hemorrhagic  group,  we  must 
take  into  consideration  whether  the  hemorrhage  is  due  to 
ulceration  in  the  vicinity  of  larger  blood  vessels  or  whether 
the  hemorrhage  is  traumatic,  brought  about  by  too  great 
exertion  when  coughing,  or  by  excessive  exercise. 

GENERAL,  HYPERSUSCEPTIBILITY.  In  pulmonary  tuber- 
culosis, as  a  rule,  the  general  hypersusceptibility  is  much 
higher  than  in  other  forms  of  the  disease.  If  we  are  to 
accept  the  theory  that  tuberculosis  of  the  lung  is  the  ter- 
tiary form  of  the  disease  and  that  the  focus  of  the  infection 
is  in  the  glands  or  bones,  whether  in  the  immediate  neigh- 
borhood or  at  a  distance, — the  hypersusceptibility  must  be 
high  to  begin  with  in  order  to  allow  of  such  extension  into 
the  lungs  from  a  quiescent  lesion.  Again,  lung  tissue  with 
the  blood  current  running  through  it  in  such  a  perfect  net- 
work invites  auto-inoculation  far  more  easily  than  does  any 
other  tissue.  This  auto-inoculation  increases  very  materially 
the  hypersusceptibility ;  so  that  here  again  we  have  a  physi- 
ological paradox  as  in  the  case  of  the  mechanism  of  im- 
munity. The  richness  in  the  circulation  tends  to  quickly 
overcome  the  tubercular  infection  ,when  it  localizes  in  the 
lung,  but  that  very  element  causes  too  large  a  supply  of  anti- 
bodies and  too  ready  an  absorption  of  the  poisonous  proteins 
which  cause  the  constitutional  reaction,  allowing  at  the  same 
time  an  extension  of  the  process.  Thus  the  hypersuscepti- 
bility in  acute  pulmonary  tuberculosis  is  very  high. 


PULMONARY  TUBERCULOSIS  113 

In  the  presence  of  a  tubercular  lesion  in  the  lung,  the 
hypersusceptibility  which  accompanies  all  other  tubercular 
lesions  must  be  considered  with  reference  to  the  lung  lesion. 
Thus,  it  may  happen  that  a  large  beginning  dose  of  tuber- 
culin may  produce  disastrous  results  in  an  old  case  of  joint 
tuberculosis  with  fistulas,  where  the  susceptibility  would  be 
low,  but  jwhere  the  contrary  is  true  because  of  an  overlooked 
incipient  apical  tuberculosis.  The  third  dilution  would  be 
safe  in  the  case  of  joint  tuberculosis  without  the  lung  lesion, 
but  in  the  presence  of  the  lung  lesion  the  susceptibility  is 
much  higher,  requiring  a  fifth  dilution  for  the  beginning 
treatment.  In  the  case  of  multiple  lesions,  we  must  treat 
the  patient  ,with  reference  to  the  lesion  which  is  accompanied 
by  the  highest  degree  of  hypersusceptibility. 

Treatment 

INCIPIENT.  As  stated  above,  under  the  class  of  inci- 
pient cases  of  pulmonary  tuberculosis  we  include  '  only 
those  with  lesions  in  the  lung  which  are  difficult  to  detect, 
requiring,  in  a  great  many  instances,  the  tuberculin  test  to 
establish  a  diagnosis.  As  soon  as  symptoms  arise  which 
define  the  diagnosis,  as  tubercle  bacilli  in  the  sputum  or  a  Hypersus- 
hemorrhage,  we  no  longer  consider  the  case  incipient  It  noTso 


therefore  follows  that  the  full  amount  of  susceptibility  in  the  those  cases 

•  11-11  nil         mi  classed  here 

cases  coming  under  this  class  has  not  yet  developed.  They  as  incipient. 
usually  come  to  a  physician  complaining  of  a  "  hanging 
on  "  cough  following  a  "  bad  cold,"  or  an  acute  infection 
such  as  influenza,  pneumonia,  pleurisy,  etc.  Or,  they  come 
complaining  of  loss  of  weight,  night  sweat,  lassitude,  a  gen- 
eral feeling  of  fatigue,  or  a  general  "  run-down  "  condition, 
which  persists  for  a  while  in  spite  of  tonic  treatment,  good 
food,  etc.,  until  eventually  a  closer  examination  reveals  a 
few  rales  at  one  or  both  apexes  with  perhaps  a  little  dull- 
ness or  increased  fremitus.  All  these  signs  lead  to  a  tuber- 
culin test  to  establish  the  presence  of  an  active  tubercular 
lesion.  The  active  pathological  process  has  been  brought 
8 


114 


TUBERCULIN  AND  VACCINE 


Begin  treatment 
in  incipient 
cases  with  the 
fourth  dilution, 
except  in  cases 
where  a  diag- 
nostic test  has 
shown  that  it 
may  be  safe 
to  begin  with 
the  third 
dilution. 


The  conclusion 
of  treatment 
is  very  simple. 


about  by  the  presence  of  a  small  amount  of  hyper  sus- 
ceptibility left  over  from  a  previous  tubercular  process. 
Whether  the  previous  process  existed  at  the  same  time 
and  was  arrested  or  whether  it  existed  as  an  adenitis  in 
infancy  or  childhood,  has  no  bearing  upon  the  present  con- 
dition. Any  pathological  process,  however  mild,  forms  a 
temporary  traumatic  area  in  the  lung  and  acts  as  trauma 
in  the  etiology  of  bone  lesions  by  attracting  the  tubercle 
bacilli  and  starting  a  tubercular  process.  The  area  of  infec- 
tion being  small,  the  number  of  (tubercle  bacilli  that  come 
into  play  is  as  yet  limited  and  as  a  result  the  protein  poisons 
have  not  yet  been  set  free  in  the  circulation  in  sufficient 
quantities  to  increase  materially  the  hypersusceptibility. 

Beginning  Treatment.  The  tuberculin  treatment  of 
incipient  pulmonary  tuberculosis  is  very  simple.  We  can 
begin  with  the  fourth  dilution  in  a  great  many  cases,  espe- 
cially in  those  cases  where  more  than  one  test  had  to  be  made 
and  where  the  amount  of  hypersusceptibility  was  thus  more 
or  less  determined.  If  a  fourth  or  fifth  test  was  required 
(see  page  23)  before  a  constitutional  reaction  was  produced, 
it  is  absolutely  safe  to  begin  the  treatment  with  the  third 
dilution. 

Conclusion  of  Treatment.  In  the  incipient  pulmonary 
tuberculosis,  it  is  rarely  necessary  to  deviate  from  the  usual 
form  of  conclusion  of  treatment  as  outlined  in  the  "  Scheme 
of  Dosage,"  for  in  limiting  the  incipient  cases  to  those  con- 
ditions where  the  tubercle  bacilli"  a-re  not  yet  present  in  the 
sputum,  we  have  no  more  difficulty  in  its  treatment  than  in 
a  simple  case  of  tubercular  adenitis.  After  the  conclusion 
of  the  series  of  inoculations  with  the  first  dilution  of  BE, 
there  remains  nothing  further  for  us  to  do  for  the  patient 
except  the  periodic  tests  over  a  period  of  two  years  for  the 
possible  return  of  hypersusceptibility. 

CHRONIC  OR  SLOWLY  PROGRESSIVE.  Among  the  slowly 
progressive  cases  of  pulmonary  tuberculosis  we  recognize  by 
far  the  majority  of  patients  that  seek  ambulatory  treatment. 


PULMOXABY  TUBERCULOSIS  .115 

A  great  many  of  these  patients  have  received  more  or  less 
of  the  hygienic  dietetic  and  climatic  treatment,  have  been 
benefited  by  it  but  are  now  suffering  from  recurrences  ;  many  The  great 
have  gotten  disgusted  .with  this  treatment  because  of  the  a^uiatorV 
slow  progress  they  were  making  toward  recovery,  have  grown  Patients  with 
impatient  at  the  length  of  time  they  were  kept  from  their  tuberculosis 
families,  their  occupations  or  their  favorite  haunts  and  have  °  * 


finally  returned  to  their  usual  mode  of  living,  taking  any 
risks  for  the  sake  of  being  comfortable  while  they  last  progressive. 
Others  return  to  their  homes  and  occupations  from  a  sana- 
torium or  mountain  resort  after  slight  improvement,  either 
under  the  impression  that  they  are  cured,  or  in  spite  of  tHe 
advice  of  the  most  expert  in  the  profession.  The  amount  of 
benefit  thus  gained  wears  off  and  they  ;are  soon  found  again  in 
the  doctor's  office,  denying  emphatically  that  they  are  ill 
enough  to  go  back  to  the  sanatorium,  and  demanding  ambu- 
latory treatment  so  that  they  may  continue  their  occupation. 

Particulary  is  this  true  a.mong  active  and  ambitious  indi-  Tuberculin 

•  11  «_'""•••  i  i  mi      ls  t'ie  °n'y 

yiduals  to  whom  inaction  is  worse  than  tuberculosis.      Ihe  treatment  to 

enforcement  of  inaction  sometimes  hastens  the  disease  in 


spite  of  the  best  treatment  and  climate.     Just  such  patients  patients 

.,,  •  t>    •  1-1  T  will  submit. 

will  give  the  most  gratifying  results  with  tuberculin  treat- 
ment. The  usual  optimism  in  the  curability  of  their  con- 
dition, added  to  the  beneficial  constitutional  effect  brought 
about  by  being  kept  at  their  occupation,  go  to  make 
a  most  favorable  prognosis  for  tuberculin  treatment.  In 
this  group  we  have  cases  that  cannot  stand  high  altitudes 
either  on  account  of  the  heart  condition  or  on  account  of 
the  existence  of  a  chronic  bronchitis,  which  in  many  in- 
stances makes  sleeping  in  the  open  during  cold  weather 
impossible. 

In  every  sanatorium  are  to  be  found  a  number  of 
chronic  cases  with  the  tubercular  condition  progressing 
favorably.  The  most  we  can  hope  for  in  this  class  of  cases 
is  an  arrest  of  the  process.  Patients  with  arrested  lesions 
are  returned  home,  the  patient  glad  to  get  home  and  the 


116 


TUBERCULIN  AND  VACCINE 


Tuberculin 
added  to 
sanatorium 
treatment 
would  increase 
the  quality  and 
permanency 
of  the  results 
obtained. 


The  relief 
produced  by 
tuberculin 
in  chronic 
ulcerative 
pulmonary 
tuberculosis 
calls  for  its 
use  even  in 
hopeless  cases. 


sanatorium  congratulating  itself  upon  obtaining  such  results. 
At  the  same  time,  it  ,is  an  ever-present  fact  that  of  the 
arrested  chronic  cases  that  go  back  to  their  previous  occu- 
pations, nearly  all  recur.  Would  it  not  be  at  least  reason- 
able to  have  added  tuberculin  properly  administered  to  the 
treatment  of  these  patients  ;and  thus  have  gained  a  large 
degree  of  immunity  against  recurrence?  Surely  the  tuber- 
culin would  not  have  interfered  with  any  other  treatment 
at  the  sanatorium.  No  one  who  ,has  used  tuberculin  exten- 
sively will  now  assert  that  any  case  which  progressed  favor- 
ably through  a  number  of  years  under  the  hygienic-dietetic 
and  climatic  treatment  would  have  terminated  otherwise 
than  favorably  if  tuberculin  had  been  added  to  the  other 
treatment. 

Again,  we  have  the  patients  in  whom  the  process  slowly 
progressed  through  a  number  of  years.  During  this  time 
new  areas  of  infiltration  constantly  occur  during  a  period 
of  lowered  resistance,  due  to  whatever  cause,  followed  by 
connective  tissue  change  during  a  period  of  heightened  re- 
sistance. This  see-saw  process  goes  on  for  years,  the  advance 
in  the  disease  never  going  far  enough  to  kill  the  patient  and 
the  healing  process  never  going  far  enough  to  cure  the 
patient,  until  the  time  comes  when  the  patient  slowly  dies 
of  insufficient  lung  tissue  for  oxygenation.  During  any  one 
of  these  periods  of  heightened  resistance,  an  artificial  boost 
would  be  sufficient  to  accomplish  a  cure.  On  the  other  hand, 
any  preventive  measure  which  would  tend  to  avoid  a  period 
of  depression  would  allow  the  healing  process  to  continue 
long  enough  and  accomplish  the  same  purpose. 

Again,  we  have  a  class  of  cases  where  the  tubercular 
process  has  gone  on  to  cavity  formation  with  sclerotic 
changes  throughout  the  lungs,  dyspnea,  cough  and  an  un- 
limited amount  of  expectoration  are  the  principal  symp- 
toms which  are  constantly  present  day  and  night.  This 
process  may  go  on  for  years  before  the  patient  is  carried 
off.  In  the  meantime  he  is  in  discomfort  and  a  taenace  .to 


PULMONARY  TUBERCULOSIS  117 

his  surroundings.    For  in  these  cases,  the  number  of  tubercle 

bacilli  present  in  the  sputum  is  more  abundant  than  in  any 

other  form  of  the  disease.     The  cavity  is  filled  with  the  best 

possible  culture  media  for  the  tubercle  bacilli  and  the  lung 

forms  the  best  incubator  for  their  growth.     These  classes  of 

cases  are  hopeless  to  begin  with  and  therefore  an  extensive 

therapy   like   tuberculin  therapy  would  seem  a  waste  of 

time.    But  that  is  not  the  case.    Just  these  cases  seem  to  cry 

for  "  relief,"  and  as  they  will  often  put  it,  "  or  death."     A 

constitutional  reaction  in  these  cases  will  not  very  frequently  Tuberculin 

occur,   in  fact,   if  it  does  occur,   the  effect  is   not  at  all  "™* 

alarming.      At    the    same    time,    the    relief    which    tuber-  tubercle  bacilli 

-i.  *ni"  i  •  •  IT  *ii  i_  from  the 

culm  will  bring  to  the  patient  is  so  marked,  especially  when  sputum. 
augmented  by  mixed  infection  vaccines,  that  it  is  almost 
criminal  to  withhold  it.  The  cough  may  not  be  diminished 
by  tuberculin,  but  its  racking  will  be  greatly  lessened. 
The  tight  feeling  in  the  chest  which  the  patients  describe  as 
"  a  grip  which  seems  to  squeeze  the  breath  out  of  their 
lungs  "  will  be  relieved  to  a  varying  extent.  It  is  surprising 
in  how  many  cases  of.  this  kind,  the  tubercle  bacilli  will  dis- 
appear from  the  sputum,  a  fact  which  speaks  loudest  for 
tuberculin  therapy  even  in  hopeless  cases.  So  that  even  if  we 
are  to  ignore  comforts  ;to  a  hopeless  case  during  the  last 
months  of  his  life,  surely  we  must  remember  that  we  must 
prevent  him  from  being  a  menace  to  his  community. 

Beginning  Treatment.  Although  the  chronic  cases, 
whether  they  have  the  fibrous  or  the  ulcerative  form  of  the 
disease,  possess  a  more  or  less  controlled  hypersusceptibility, 
it  is  best  to  begin  with  the  fifth  dilution  of  OT  and  continue 
in  the  usual  way  three  or  four  weeks.  If  a  distinct  focal 
reaction  is  elicited  by  every  inoculation,  especially  if  ac- 
co"  .panied  by  a  local  reaction — even  if  only  mild — it  is 
best  to  continue  the  treatment  throughout,  according  to  the 
scheme  outlined  in  Table  I,  page  57.  On  the  other  hand, 
if  the  tuberculin  seems  to  produce  no  impression  on  the 
patient's  condition,  better  results  can  be  obtained  by  a 


118  TUBERCULIN  AND  VACCINE 

in  the  quicker  approach  to  the  maximum  tolerance.     This  can  be 

treatment  done  by  increasing  the  increase  at  every  inoculation,  instead 

wro'Ic™  to*  of  increasing  the  increase  at  every  other  inoculation,  until 

the  maximum  a  distinct  focal  reaction  has  been  elicited  by  two  or  three 

tolerance  may  .  . 

be  advisable  successive  inoculations.  At  this  point,  it  would  be  best  to 
miny'cVses.  discontimijB  the  more  rapid  increase  and  return  to  the  usual 
method  of  increasing  the  increase  at  every  other  inocula- 
tion, without  waiting  for  a  constitutional  reaction.  Should 
a  constitutional  reaction  take  place  before  we  have  re- 
duced the  rapidity  of  the  increase,  the  usual  indications 
following  the  constitutional  reaction  should  be  complied 
with ;  i.  e.,  after  an  interval  of  one  week,  resume  the  inocu- 
lations with  a  dose  equivalent  to  the  third  last,  and  not  only 
should  the  increase  be  reduced  to  the  amount  of  increase 
given  at  the  commencement  of  treatment,  but  this  increase 
should  not  be  increased  more  rapidly  than  at  every  other 
inoculation.  (Table  II,  page  59.)  From  this  point,  the 
usual  routine  of  doses  is  continued. 

Conclusion  of  Treatment.  The  conclusion  of  treatment 
in  a  case  of  fibrous  phthisis  does  not  differ  greatly  from  that 
required  in  a  case  of  surgical  tuberculosis.  In  a  great  many 
cases  the  removal  of  hypersusceptibility  with  OT  would  be 
sufficient  to  effect  a  cure  as  [far  as  the  tubercular  infection 
is  concerned.  The  localized  hyperemia  brought  about  by 
the  focal  reaction  in  response  to  the  tuberculin  inoculation 
is  sufficient  to  encourage  the  already  present  tendency  to 
scar  tissue  formation.  Since  a  complete  cure  in  fibrous 
phthisis  is  prevented  by  the  tubercular  process  keeping 
slightly  ahead  of  the  scar  tissue  formation  or  healing  pro- 
cess, the  slightest  (delay  in  the  progress  of  the  infection  plus 
the  stimulation  of  the  healing  process  by  the  focal  reac- 
tion, makes  a  cure  in  this  class  of  cases  almost  certain. 
However,  since  we  very  often  encounter  large  areas  of 
fibrosis  in  which  the  circulation  is  necessarily  poor,  it  would 
be  best  to  add  ,a  course  of  BE  inoculations  according  to  the 
principle  laid  down  in  Table  III,  page  60. 


PULMOXAKY    TUBEKCULOSIS  119 

The  essential  elements  in  the  conclusion   of  treatment  Treatment  for 

the  mixed 


lire  the  treatment  of  mixed  infection,  and  the  removal  of  the  infection 

be  most  ' 

elements  which  first  encouraged  the  spread  of  the  tubercular  important        * 
process,  as  may  be  gathered  from  a  complete  physical  ex-  conclusion  of 
animation  and  a  more  detailed  history.     I  am  referring  to  *r«atment- 
the  possible  presence  of  nasal  obstruction,  throat  complica- 
tions, chronic  bronchitis,  and  anemia,  —  especially  when  due 
to  constipation. 

The  habits  of  the  patient  must  be  regulated  with  a  view  ™'  suPervision 

of  the  patient's 

to  the  normal  existence  which  he  is  to  resume  from  now  on.  mode  of  life 

ft-,  -,  .  •      i        i  •  i          and  habits 

We    must    take   great   pains    to    remind    the    patient   that  must  continue 
although  he  is  no  longer  ill,  he  must  not  resume  injurious  d^"n^*^ 
habits    which    may    have    facilitated   his    infection    in    the  that  he 

,.  i  rm  .  ,  .  .,  .     ,  .     remains  under 

nrst  place.     Ihese  instructions  are  more  easily  carried  out  observation. 
by  our  rule  of  keeping  the  patient  within  our  professional 
sphere  for  two  years  following  the  conclusion  of  his  treat- 
ment.    In  these  cases  especially,  the  testing  of  the  patient 
every  three  months  should  not  be  overlooked. 

The  -greatest  care  must  be  exercised  in  the  conclusion  of 
treatment  of  the  ulcerative  form  of  chronic  pulmonary  tuber- 
culosis.    Here  we  have  a  condition  similar  to  tuberculosis  The  conclusion 
of  the  bone.     Just  as  in  bone  tuberculosis  a  cavity  may  in  theeau™  era- 


persist  after  the  tubercular  infection  is  ended,  —  so  also  in  ti 

•  of  chronic 

the  ulcerated  form  of  pulmonary  tuberculosis  with  cavity  phthisis  should 
formation,  we  must  not  expect  obliteration  of  the  cavity  with  j^^"^^ 
the  eradication  of  the  tubercular  infection  by  means  of  the  utmost  care. 
tuberculin.     Although  there  is  a  similarity  in  the  process  of 
formation  of  a  bone  cavity  and  of  a  lung  cavity,  we  have  an 
added  disadvantage  in  the  treatment  of  the  latter,  in  as  much 
as  in  a  lung  cavity  we  cannot  by  taeans  of  bismuth  paste  pre- 
vent the  accumulation  of  suppurative  material.     In  addition 
to  that,  we  are  constantly  forcing  infectious  organisms  into 
such   a  cavity  by  the  process  of  inhalation.      Fortunately, 
two  factors  exist  which  rescue  this  situation  from  becoming 
hopeless:  the  reflex  cough,  and  perfect  drainage  by  means 
of  the  bronchial  tube.     We  must  utilize  these  two  factors 


120 


TUBERCULIN  AND  "VACCINE 


Opiates  should 
be  used  very 
guardedly  in 
cases  of 

cavitation, 
as  our  only 
means  of 
emptying  the 
cavities  is 
through  the 
reflex  cough. 


Treatment  of 
the  mixed 
infection 
should  not  be 
overlooked. 


to  the  best  advantage  so  long  as  the  cavity  exists.  And 
even  though  exhaustion  and  lack  of  sleep  may  make  it  neces- 
sary to  employ  remedies  to  lessen  the  amount  of  the  cough, 
we  must  use  them  guardedly.  By  the  too  generous  use  of 
these  drugs,  infected  and  irritating  material  may  become 
pent  up  which  not  only  does  harm  by  remaining  in  the 
cavitv,  but  which,  through  further  accumulation  might  be 
forced -into  the  bronchioles  and  vesicles  of  the  surrounding 
'  lung  tissue,  spread  the  infection,  and  even  tend  to  produce 
a  pneumonic  process.  It  is  self-evident,  therefore,  that  we 
must  keep  our  patient  constantly  fortified  against  mixed 
infection.  A  detailed  description  of  mixed  infection  treat- 
ment and  prevention,  and  methods  that  we  must  utilize  to 
encourage  the  contraction  of  the  lung  cavity  will  be  found 
in  Part  III  of  this  work.  I  call  attention  to  it  here,  in  order 
to  emphasize  its  importance.  Tuberculin  is  hopeless  here 
without  attention  to  these  details.  Since  the  time  necessary 
for  the  healing  of  a  lung  cavity  is  considerably  longer  than 
the  healing  of  the  fibrous  form  of  lung  infection,  and  as  it 
is  advisable  to  keep  the  patients  under  the  influence  of  tuber- 
culin while  they  are  still  under  treatment,  it  is  best  to  utilize 
the  longer  of  the  two  methods  of  BE  administration  (Table 
IV.  page  60.) 

ACUTE  OK  ACTIVE.  Acute  pulmonary  tuberculosis  in- 
cludes in  its  category  the  most  difficult  cases  to  be  treated 
by  any  method,  especially  ;with  tuberculin.  At  the  same 
time,  this  class  of  cases  count  the  greatest  mortality  among 
them,  so  that  a  special  method  of  therapy  becomes  much 
more  urgent  here  than  in  any  other  form  of  the  disease. 
If  the  careless  use  of  tuberculin  will  produce  the  most 
harm  in  acute  or  active  tuberculosis,  we  have  at  least 
this  consolation  and  warrant  for  persisting  in  its  use:  the 
fact  that  we  cannot  do  much  to  increase  the  serious- 
ness of  the  condition  as  it  presents  itself  to  us.  Again,  we 
can  make  our  plea  for  tuberculin  treatment  in  these  con- 
ditions more  persistently  now  that  we  have  a  method  of 


PULMONARY  TUBERCULOSIS  121 

tuberculin  administration  which  has  raised  the  degree  of 
safety  to  such  an  extent  that  it  may  be  safely  used  in  acute 
conditions.  Any  general  practitioner  who  has  used  this 
method  of  tuberculin  administration  in  but  one  or  two  eases 
where  its  us©  [was  not  very  difficult,  is  qualified  to  use  it  in 
active  pulmonary  tuberculosis.  We  have  only  to  classify 
our  cases  in  order  to  be  able  to  apply  the  proper  auxiliary 
treatment.  We  must  be  able  to  recognize  the  difference 
between  fever  due  to  auto-inoculation  and  fever  due  to  mixed  A  careful 

.      ...  -,  i  .  distinction 

infection;  between  hemorrhage  due  to  an  ulcerative  process  astothe 
and  hemorrhage  due  to  trauma  that  is  brought  about  by  ex-  "^perature 
cessive  coughing;  between  an  afebrile  case  with  an  ulcera-  and  hemorrhage, 

and  a  more 

tive  process  belonging  to  the  active  form  of  the  disease  and  guarded 
which  is  afebrile  on  ,account  of  having  excellent  drainage  ^oTher*  ' 
by  being  in  close  proximitv  to  a  larger  bronchus  and  an  ^mPtomswl11 

J  "  discover  their 

afebrile  case  which  belongs  to  the  chronic  and  slowly  pro-  cause  to  be 

,,,,..         .  in!  other  than  the 

gressive  type.  .  By  making  careful  distinctions,  we  shall  have  tuberculin 
achieved  two  important  aims  which  will  help  materially  in 
the  success  of  tuberculin  therapy.  In  the  first  place  we 
shall  have  removed  many  an  obstacle  to  the  successful 
prosecution  of  a  course  of  tuberculin  treatment,  by  treating 
symptoms  which  on,  closer  analysis  will  be  found  to  b© 
due  to  other  causes  than  negative  effects  of  the  tuberculin. 
And  in  the  second  place,  we  shall  have  removed  the 
necessity  of  expert  classification  of  patients  in  order  to 
judge  whether  tuberculin  therapy  is  indicated  or  contra- 
indicated.  This  will  be  a  great  gain,  for,  instead  of  giving 
so  much  consideration  to  supposed  contraindications  to 
tuberculin  therapy,  we  shall  give  closer  attention  to  the 
treatment  of  the  elements  which  bring  about  those  contra- 
indications. In  this  way,  we  shall  do  much  to  remove  the 
mysticism  that  surrounds  tuberculin  therapy  and  in  its 
place  discover  many  details  in  the  condition  of  our  patients. 
These  details  have  been  overlooked  as  a  result  of  the  hope- 
lessness which  we  have  heretofore  associated  with  the  acute 


1-22 


TUBERCULIN  AND 


The  treatment 
of  acute  or 
active  phthisis 
is  begun  with 
o.oooooi  c.c. 
of  OT,  except 
in  cases  where 
the  first  few 
inoculations 
cause  distinct 
local  reactions, 
when  the  dose 
should  be 
o.ooooooi  c.c. 


The  more  rapid 

tuberculin 

administration 

is  indicated 
where  it  is 
urgent  to 
reach  the 
maximum 

tolerance. 


condition,  but  if  accounted  for  will  go  far  to  improve  the 
condition  of  the  patient. 

Beginning  Treatment.  It  is  quite  safe  to  begin  treat- 
ment with  the  fifth  dilution  in  nearly  all  cases  of  acute  or 
active  pulmonary  tuberculosis.  There  are,  however,  some 
exceptions,  and  these  can  be  placed  into  two  main  classes. 

First,  there  are  those  acute  cases  where  the  tubercular 
process  is  recent,  having  begun  as  an  acute  infection.  If 
after  the  first  few  inoculations  with  the  fifth  dilution,  local 
reactions  are  prominent,  it  may  point  to  the  presence  of  a 
constitutional  reaction  which  is  masked  by  a  high  tempera- 
ture already  present  as  a  result  of  the  active  process.  It 
is  therefore  better  to  go  back  to  the  sixth  dilution  in  case 
of  distinct  local  reactions  following  the  beginning  with  the 
fifth  dilution. 

Second,  there  are  those  cases  of  acute  or  active  pul- 
monary tuberculosis  which  jare  acute  exacerbations  of  a 
chronic  process  that  has  existed  for  some  time.  These  acute 
exacerbations  are  brought  about  yery  frequently  by  mixed 
infection. 

All  tubercular  affections  in  the  lung  indicate  beginning 
treatment  with  the  fifth  dilution.  However,  that  may  be  far 
from  the  maximum  tolerance,  and  since  it  is  necessary  to 
reach  that  maximum  tolerance  in  these  cases  as  soon  as  pos- 
sible, it  is  best  to  proceed  with  the  dosage  by  increasing  the 
increase  at  every  inoculation  instead  of  at  every  other  inocu- 
lation. For  example,  the  sequence  of  dosage  would  be  as 
follows:  Solution  Number  V,— 0.10,  0.12,  0.16,  0.22,  0.30, 
0.40,  0.52  c.c.  and  so  on.  This  more  rapid  increase  may  be 
kept  up  until  a  near  reaction  is  obtained,  viz. :  a  distinct 
local  reaction;  distinct  focal  manifestations;  the  persistent 
occurrence  of  headache  after  two  or  three  successive  inocu- 
lations; or  any  other  symptoms  that  may  point  to  the 
approach  of  a  constitutional  reaction. 

Conclusion  of  Treatment.     The  conclusion  of  treatment 
must  also  take  cognizance  of  the  time  of  the  origin  of  the 


PULMONARY  TUBERCULOSIS  123 

acute  process,   that  is — whether  it  is   a  beginning  process 
with  low  resistance, — or  whether  it  is  an  acute  exacerbation  The  conclusion 
of  an  old  process.     In  the  former  case,  the  conclusion  of  ismuch 
treatment  presupposes  the  checking  of  the  rapiditv  of  the  s[mPlerthan 

the  beginning 

process,   and  being  an  early  process  it  would  require  the  of  treatment, 
simplest  conclusion.    This  means  that  after  OT  inoculations  proces*ia  " 
are  finished,  the  BE  is  administered  as  shown  in  Table  III.  checked> 

repair  is 

For  two  years  after  the  conclusion  of  the  inoculations  of  rapid  in 
Bacillary  Emulsion  tri-monthly  tests,  as  described  elsewrhere,  conditions, 
are  required. 

Prognosis  and  Results. 

The  prognosis  in  pulmonary  tuberculosis,  when  viewed 
from  the  standpoint  of  immunotherapy,  must  be  considered 
at  three  distinct  periods  in  relation  to  tuberculin  treatment. 

The  first  period  is  when  the  patient  applies  for  treat- 
ment.    An  examination  is  made,  and  a  fair  knowledge  is 
obtained  from  a  physical  examination,  a  microscopic  exami- 
nation of  the  sputum,  a  three-day  temperature  record,  and  The  prognosis 
an  X-ray  picture  of  the  lungs.     These,  together  with  the  beginning  of 
history  of  the  course  of  the  disease  prior  to  the  beginning  ^"*™*nt 
of  treatment  with  tuberculin,  when  considered  .together,  form  guarded  in 
a  basis  for  a  fairly  accurate  prognosis.     The  history  must,  no  element 
of  course,   take  accurate  account  of  the  patient's  loss  of  °verlooked 

which  may 

weight  previous  to  this  examination — whether  it  was  rapid  have  a 
or  slow — whether  the  present-day  treatment,  as  the  hygienic-  upeonTt8 
dietetic  and  climatic  treatment  was  applied  and  what  effect 
it  produced  upon  him — whether  it  was  discontinued  on  ac- 
count of  the  failure  of  the  treatment,  or  whether  the  patient 
was  impatient  and  did  not  give  it  a  fair  trial.  Again,  what 
are  the  habits  of  the  patient  and  his  mental  attitude  towards 
his  occupation  ?  Can  the  failure  of  the  climatic  treatment 
be  attributed  to  an  intense  psychic  effect,  caused  by  being 
deprived  of  his  ordinary  habits  and  pursuits?  All  these  ele- 
ments play  a  far  greater  role  in  determining  the  prognosis 
of  pulmonary  tuberculosis  than  we  have  hitherto  realized ;  in 
fact,  these  factors  play  just  as  important  a  part  as  the  stage 


124  TUBERCULIN  AND  VACCINE 

of  the  disease.  To  a  patient  with  a  fairly  advanced  tubercu- 
lar lesion  in  the  lung,  who  has  demonstrated  an  inability  to 
keep  away  from  his  ordinary  pursuits,  w©  can  offer  a  much 
better  prognosis  with  the  ambulatory  tuberculin  treatment 
than  to  an  incipient  case  who  is  willing  to  submit  to  the 
tuberculin  treatment  through  bravado,  but  is  constantly 
worried  that  he  has  probably  chosen  a  hazardous  method  of 
treatment  and  would  have  done  better  with  a  change  of  cli- 
mate, etc.  We  must,  in  all  events,  remember  that  permanent 
damage  will  result  after  destruction  of  lung  tissue  and  the 
symptoms  remaining  after  the  tubercular  process  has  been 
cleared  up,  will  be  in  proportion  to  the  amount  of  destruc- 
tion that  has  taken  place  before  the  process  has  been  checked. 
Temperature  has  a  great  bearing  upon  the  prognosis  at 
the  beginning  of  treatment.  If  a  patient  runs  a  high  tem- 
perature, prognosis  is  very  difficult  until  the  temperature 
has  been  checked  or  at  least  its  nature  determined.  Jf  it 
is  due  to  auto-inoculation,  it  usually  points  to  a  rapid  pro- 
gress with  a  tremendous  hypersusceptibility  and  conse- 
quently makes  the  prognosis  far  graver  than  when  the 
temperature  is  due  to  mixed  infection.  In  the  latter  case, 
vaccines  have  been  successful  rendering  the  prognosis  more 
hopeful  when  the  temperature  is  caused  by  the  mixed 
infection. 

The  second  period  is  when  jthe  patient  has  had  sufficient 
once  the  tuberculin  treatment  to  demonstrate  a  response.     By  this 

tuberculin  .  . 

treatment  has  time,  a  great  many  doubts  which  existed  when  the  patient 
aep™"tiveated  first  aPPlied>  have  been  cleared  up.  The  progress  of  a  tern- 
response,  the  perature  at  the  beginning  of  treatment  will  at  this  time  make 
barring  *  itself  evident.  We  shall  know  whether  the  temperature  is 

^"0^*  controllable  or  otherwise;  and  if  it  was  due  to  mixed  infec- 
™ybe  tion,  whether  or  not  it  responded  to  vaccine  treatment.  A 

aTfavorabie.  change  in  the  quantity  of  the  sputum,  or  in  its  consistency, 
or  in  both,  will  have  a  (decided  bearing  upon  our  estimation 
of  the  efficacy  of  the  immune  response  we  have  been  able  to 
elicit.  A  more  decided  localization  of  the  physical  signs  in 


FIG.  35. — A  young  man,  twenty-two  years  of  age,  a  bank  clerk  by 
occupation. 

About  six  months  before  he  came  to  me  for  the  first  consultation, 
his  brother  died  of  pulmonary  tuberculosis.  He  himself  was  always 
well,  but  he  had  grown  very  rapidly  in  height,  and  became  very  thin. 
About  three  years  ago,  he  had  a  severe  attack  of  grippe,  which  was  fol- 
lowed by  a  cough  and  the  presence  of  tubercle  bacilli  in  his  sputum. 
He  went  to  the  mountains  where  he  recuperated  and  returned  after 
about  four  months'  stay,  apparently  well.  ,0ne  year  and  a  half  ago,  he 
began  to  cough  again,  had  night  sweats,  and  hectic  flush.  In  spite  of 
the  recent  death  of  his  brother  and  the  fact  that  his  own  sputum  was 
once  positive,  he  refused  to  take  his  condition  seriously,  until  I  con- 
vinced him  that  it  was  an  active  recurrence.  Upon  the  advice  of  an- 
other physician  he  decided  to  refuse  tuberculin  treatment,  and  went 
to  Saranac  Lake,  where  he  remained  three  months  with  little  improve- 
ment. He  finally  lost  patience  with  the  "  rest  in  bed,  and  with  the  ever 
present  tubercular  patients  all  around  him,"  and  returned  to  New  York 
City,  where  he  applied  for  tuberculin  treatment  at  my  office. 

At  this  time  there  were  physical  signs  throughout  the  right  lung, 
and  at  the  apex  of  the  left  lung.  Tubercle  bacilli  in  the  sputum  num- 
bered about  fifteen  to  twenty  in  a  microscopic  field. 

This  X-ray  photograph,  taken  at  this  time,  shows  considerable  infil- 
tration of  the  upper  two-thirds  of  the  right  pulmonary  field.  The  infil- 
tration seems  to  be  of  a  connective  tissue  type.  The  left  pulmonary 
field  is  clear  except  for  slight  clouding  (indicating  a  recent  process). 


PULMOXAKY  TUBERCULOSIS  .  125 

the  chest  forms  an  important  prognostic  element  which  oc- 
curs as  a  result  of  effective  tuberculin  treatment.  It  indi- 
cates the  disappearance  of  inflammatory  changes,  radiating 
from  the  actual  point  of  tubercular  infection  during  the  more 
active  tubercular  process.  This  can  only  point  to  a  favorable 
response  to  the  treatment  and  of  course  it  must  necessarily 
improve  the  outlook  for  the  patient.  An  improved  mental 
attitude  as  a  result  of  improvement  in  the  general  condition 
following  the  first  inoculations  of  tuberculin  will  point  to  a 
better  prognosis  than  perhaps  an  improvement  of  greater 
degree  without  the  mental  effect. 

Although  tuberculin  may  elicit  a  response  from  the  first  A  favorable 
dose,  it  nevertheless  more  often  occurs  after  the  maximum  "tub^rcuHn0" 
of  tolerance  has  been  reached.      It  therefore  may  require  maybecome 

-1  evident  early 

the  positive  phase  following  a   constitutional   reaction   be-  inthetreat- 

f  i     -1  n    .    -1  _  .-.-I     -i  .      ment,  however 

fore   a   real  beneficial   immune   response  will    become   evi-  itmaynot 
dent  through   the   tuberculin   treatment.      Once   a   distinct  appear  until 

"111-  •  •  late  in  the 

response  to  the  tuberculin  treatment  is  noticed,  the  prog  treatment. 
nosis  becomes  a  great  deal  jbetter,  for  nothing  but  an  unusual 
occurrence,  such  as  an  unduly  severe  tuberculin  reaction,  or 
intercurrent  disease,  can  stay  the  favorable  progress  wifli 
tuberculin  inoculation  once  the  patient  Jias  demonstrated  a 
response. 

The  third  period  is  the  prognosis  at  the  conclusion  of 
the  course  of  tuberculin  treatment.     At  this  point  it  is  not 
strictly  prognosis  that  we  have  to  consider,  but  the  patient's 
present   condition   [and    its  bearing  on  his   future  health.  The  prognosis 
What  is  the  amount  of  permanent  damage  left  behind  —  how  **  j^",,^,,  of 


much  of  the  function  of  the  lungs  will  be  permanently  inter-  treatment 

will'depend 

fered  with  as  a  result  of  such  damage  —  how  much  of  the  upon  the 
pathological  change  was  brought  about  by  a  mixed  infec-  p™^e°nft 
tion  —  and  how  well  this  mixed  infection  was  under  control  damage 

1-1111  •  produced  by 

at  the  time  —  all  these  elements  have  a  great  bearing  upon  the  infection. 
the  final  results  we  may  obtain  with  tuberculin.     If  frequent 
repetition  may  be  pardoned,  I  will  again  state  that  in  our 
expectations   regarding   the   most    optimistic    results   from 


1 2  G  .  TUBEBCUUN    AXD    VACCINE 

tuberculin  therapy  we  cannot  overlook  the  fact  that  with 
the  removal  of  tuberculosis  as  an  ^infection,  ,we  do  not 
eliminate  the  damage  resulting  from  it.  Hence  the  condi- 
tion of  the  patient  at  the  conclusion  of  successful  treatment 
will  depend  largely  upon  ,the  amount  and  position  of  the 
pathological  changes  which  have  taken  place  during  the 
life  of  the  infection. 

The  report  of  quantitative  results  obtained  with  tuber- 
culin in  the  treatment  of  pulmonary  tuberculosis  would  have 
to  embody  such  a  large  number  of  cases  to  make  an  impres- 
sion, that  it  is  still  beyond  my  experience  to  include  a  suffi- 
cient number  in  this  work.    For  me  to  attempt  a  statistical 
statistics  are       exposition  of  the  results  obtained  as  given  in  the  literature 
SaU"pJact°icaim      ou  tne  subject  would  'be  useless  for  two  reasons :    First,  such 
guide."  statistics  may  be  gathered  from  almost  any  work  on  the 

subject,  as  most  of  the  works  on  tuberculin  treatment  to  be 
found  at  the  present  day  consist  mainly  of  statistics  and 
consensus  of  opinions.  Secondly,  I  have  here  presented  a 
more  simplified  and  more  easily  adaptable  method  of  tuber- 
culin administration,  which  will  produce  even  better  results 
than  have  been  obtained  with  tuberculin  heretofore. 

As  to  the  permanency  of  the  results  obtained  from  the 

treatment  of  pulmonary  tuberculosis  with  tuberculin — I  have 

laid  great  stress  upon  the  tuberculin  test  to  be  applied  to  the 

A  greater  patient  for  two  years  after  the  conclusion  of  treatment.    This 

number  of  -11111  i  c 

permanent          necessarily  adds  to  the  results  an  element  of  permanency 

cures  and  not  obtained  in  former  reports.    Since  it  is  true' that  the  con- 

more  lasting 

results  are  elusion  of  treatment  is  more  or  less  empirical,  just  as  in 

brought  about          ,1  f   ,  i        i         •         •  c    ,  i  i 

by  a  more  tne  case  °*  tne  beginning  of  treatment,  there  are  those  cases 

where  the  conclusion  of  treatment  may  not  have  gone  far 

conclusion  of 

tuberculin  enough,  and  a  recurrence  of  hypersusceptibility  may  take 

pius'the*11'  place.     And  as  it  is  well  knewn  that  a  recurrence  of  the 

hypersnsceptibility  is  a  forerunner  of  the  recurrence  of  the 
disease,  it  was  found  necessary,  in  order  to  assure  the  per- 
manency of  the  results  obtained,  to  test  the  patient  with 
tuberculin  at  certain  intervals  for  a  period  of  time  after  the 


tests. 


PULMCXXABY   TuBEBCULOSIS.  127 

conclusion  of  the  treatment.  These  tests  are  made  in  order 
to  determine  in  which  of  the  cases  the  conclusion  of  treat- 
ment was  not  carried  far  enough.  Thus  we  get  ahead  of  the 
recurrence  of  the  disease  by  overcoming  the  recurrence  of 
hypersusceptibility.  That  is  the  reason  why  the  results  I 
have  obtained — although  quantitatively  not  sufficient  for  an 
autho'ritative  expose, — can  still  claim  qualitatively  a  superi- 
ority over  former  results. 

One  more  element  should  be  reckoned  with  in  the  per-  careful 
manency  and  frequency  of  better  results  obtained, — that  is  *"^£!ed 
the  treatment  of  mixed  infection  which  is  given  prominence  inaction  adds 

.  .  greatly  to  the 

in   this  work    (see  Part  III).      I   am   quite  certain  that  permanency 
with  proper  attention  given  to  the  subject  of  mixed  infection 
with  due  consideration  to  its  .vaccine  treatment,  an  element 
will  be  added  to  the  matter  of  tuberculin  therapy,  which 
will  add  both  quality  and  permanency  to  the  results  obtained. 

More  important  than  statistics  are  the  results  produced  The  feeling 
in  the  various  symptoms  during  tuberculin  treatment.     These  bright  a'bout 
results    encourage   both    the   patient    and   physician.      The  by  tuberculin, 

.,   .  ~  .  exerts  a  good 

.earliest  and  most  striking  effect  that  is  noticed  is  the  sense   influence  on 
of  well-being  011  the  part  of  the  patient.     Granting  .that  the  ^JJ.™™^ 
larger  part  is  brought  about  'by  "  suggestion  and  auto-sug-  the  patient, 
gestion  " — it  still  adds  an  element  which  is  most  important 
to  the  favorable  progress  in  the  treatment  of  any  disease. 

Pain.     Tuberculin  has  a  distinct  anti-phlogistic  action  Tuberculin 
upon  pain  brought  about  by  a  tubercular  condition,  and  will  ^/^'for 
thus  be  found  a  great  aid  in  relieving  a  symptom  which  tubercular 
causes  most  of  the  distress.     However,  pain  produced  by 
pleuritic   adhesions   occasionally  persists  >,even   in   patients 
who  have  noticeably  improved,  or  remained  well  for  years. 

Digestion.     Both  appetite  and  digestion  markedly  im-  Digestion 
prove.     That  may  be  brought  about  by  the  general  well-  andaPPetite 

improve. 

being  which  is  most  sedative  in  its  action  upon  neurotic 
digestion,  or  upon  the  improvement  of  the  general  tone  of 
the  digestive  apparatus. 

Weight.     The  tuberculin  treatment  must  be  considered 


128 


TUBERCULIN  AND  VACCINE 


The  increase 
in  weight 
brought  about 
by  tuberculin 
is  always 
accompanied 
by  increased 
strength. 


Tuberculin 
is  distinctly 
antipyretic 
in  tubercular 
fever. 


The  pulse 
improves  with 
the  other 
symptoms. 


Cough  is 
diminished, 
and  becomes 
less  irritating. 


as  having  a  direct  influence  upon  the  weight  of  the  patient. 
That  may  be  noticed  upon  the  ambulatory  patients  who  can- 
not change  their  mode  of  living  in  any  way.  (These  patients, 
although  they  liave  not  gained  in  weight  previous  to  the 
tuberculin  treatment,  gain  in  weight  soon  after  the  institu- 
tion of  tuberculin  treatment.  And  since  nothing  but  tuber- 
culin has  been  added  to  the  treatment,  the  result  (must  be 
attributed  to  .tuberculin.  Of  course,  here  again  we  may 
attribute  such  gain  to  the  influence  .of  tuberculin  on  the 
general  (Well-being,  and  to  the  improvement  of  digestion. 

Fever.  The  effect  of  tuberculin  on  fever  cannot  be  mis- 
taken. Tuberculin  acts  as  a  direct  anti-pyretic,  and  nothing 
will  reduce  temperature  due  to  the  tubercular  infection  as 
quickly  as  tuberculin  treatment.  Adverse  opinion  as  to  the 
effect  of  tuberculin  on  fever  may  be  attributed  to  two  dis- 
tinct reasons;  first,  the  failure  to  differentiate  between 
pyrexia  due  to  tubercular  auto-inoculation,  and  that  due  to 
mixed  infection  or  other  conditions;  secondly,  a  faulty 
technic  in  tuberculin  administration. 

Pulse.  The  influence  of  tuberculin  on  the  pulse  is  in. 
direct  proportion  to  its  influence  on  the  temperature  and 
general  well-being  of  the  individual.  If  the  tachycardia  is 
due  to  a  mild  carditis  which  resulted  from  a  long  standing 
infection,  tuberculin  will  have  no  effect  upon  it.  It  will 
have  to  be  treated  as  a  heart  condition  so  .as  not  to  allow  it 
to  dissipate  the  beneficial  effects  obtained  from  tuberculin. 

Cough.  Cough  may  be  increased  as  a  result  of  the  focal 
reaction  accompanying  the  tuberculin  treatment,  but  it  is 
rendered  less  irritating  and  less  strenuous.  Later,  as  the 
effect  of  the  tuberculin  treatment  becomes  cumulative,  the 
cough  diminishes.  This  is  especially  true  of  the  dry  and 
irritating  cough.  Careful  attention  must  be  given  to  cough 
originating  from  other  sources  than  the  tubercular  process, 
such  as  naso-pharyngeal  conditions,  mixed  pulmonary  in- 
fections, etc.  Many  a  patient  has  lost  patience  with  tJie 
tuberculin  treatment  because  of  the  persistence  of  an  annoy- 


FIG.  30  shows  an  X-ray  photograph  of  the  chest  of  the  same  young 
man*  ten  months  later,  at  the  conclusion  of  a  successful  tuberculin  treat- 
ment. The  infiltration  has  greatly  diminished,  the  clouding  has  dis- 
appeared, while  the  apices  alone  show  signs  of  a  former  tubercular 
lesion  (permanent  damage).  For  the  past  five  months  there  have 
been  no  tubercle  bacilli  in  the  sputum,  there  is  rarely  any  cough  and  the 
patient  has  been  able  to  work  ninety  per  cent,  of  the  time  during  his 
tuberculin  treatment. 

*  As  Fig.  35. 


PULMOXAKY   TuBEKCULOSIS  129 

ing  cough  after  months  of  tuberculin  treatment.  The  physi- 
cian should  demonstrate  this  cough  as  originating  from  a 
condition  quite  apart  from  the  tubercular  process,  and  treat 
it  as  such  without  interrupting  the  tuberculin  treatment 
which  was  producing  the  desired  effect  on  the  tubercular 
process. 

Hemoptysis.      The  general  belief  that   tuberculin   will  Tuberculin 
produce  pulmonary  hemorrhage  or  even  increase  hemorrhage  Beneficial 
when  already  present,  is  based  upon  a  fallacy  born  of  preju-  effect  on 

hemoptysis. 

dice.  Tuberculin  does  not  tend  to  produce  hemoptysis.  On 
the  contrary,  it  will  slowly  diminish  and  finally  permanently 
stop  recurrent  hemoptysis. 

Expectoration.      The  amount  of  expectoration  may  in-  The  tubercle 
crease   at  the  beginning  of  tuberculin  itreatment,   but  the  baciiiiwm 

.  '  more  frequently 

consistency  of  the  sputum  will  reveal   a  beneficial  effect,  disappear  from 

The  sputum  becomes  thinner  and  is  jmore  easily  brought  up.  *^erisnput 

The  microscopical  change  in  the  sputum  has  not  escaped  the  tuberculin 

notice  of  any  physician  using  the  tuberculin  treatment.     The  than  during 

diminution  in  the  number  of  tubercle  bacilli  is  striking,  fol-  any°ther 

treatment. 

lowed  by  a  more  rapid  and  more  frequent  disappearance  of 
the  tubercle  bacilli,  than  with  any  other  form  of  treatment. 
Even  in  hopeless  conditions,  a  disappearance  of  the  tubercle 
bacilli  from  the  sputum  may  be  accomplished  with  the  tuber- 
culin treatment.  This  fact  alone  offers  sufficient  argument 
for  the  use  of  tuberculin  in  patients  that  are  hopeless  as 
far  as  a  cure  is  concerned. 

Physical  Signs.     The  physical  signs  are  modified  by  tu-  Oniysuch 

-,.  .  ,  ,.  physical  signs 

bercuhn  treatment  in  proportion  to  the  amount  01  perma-  persist  as  are 
nent  damage  produced  before  the  immune  response  became  produced  by 

the  distortion 

sufficient  to  check  the  infection.     Since  scar  tissue,  distorted  oftheiung 
lung  structure,  calcareous  infiltration,  constriction  of  bron-  tnVhtaHng*8 
chial  tubes,  etc.,  will  produce  physical  signs,  it  stands  to  of  the  disease- 
reason  that  such  signs  will  persist,  for  any  or  all  of  these 
pathological  changes  form  part  of  the  healing  process.     Of 
course  in  early  incipient  cases  all  physical  signs  may  dis- 
appear.    When  Tripier  said  that  once  a  tubercular  lesion 


130  TUBERCULIN  AND  VACCINE 

in  the  lung  presents  physical  signs,  the  lesion  is  incurable — 
he  really  referred  to  the  permanent  damage, — lung  tissue 
never  reforms, — scar  tissue  must,  take  the  place  of  the  de- 
stroyed lung  and  thus  change  the  normal  physical  signs. 
Fibrosis— the  Pathology.     The  consensus  of  opinion  throughout   the 

hMiilTgTn0*        literature  as  to  the  difference  in  the  pathological  changes  in 

tuberculosis—      tuberculin  treated  patients  and  those  treated  without  tuber- 
is  usual  in 

tuberculin  culin,  seems  to  leave  no  doubt  that  fibrosis  occurs  far  more 

parents.  frequently  in  the  former  than  in  the  latter.    This  fact  offers 

another   important   reason  for   the  use  of  tuberculin,  for 

"scar  tissue  formation  is  in  the  nature  of  all  healing  processes. 

It  therefore  offers  a  more  lasting  effect  than  any  other  form 

of  healing. 

X-ray  Findings.    A  wider  adoption  of  jRoentgenography 

in  pulmonary  tuberculosis  in  recent  years  has  become  a  great 
Roentgen-  aid  in  the  determination  of  results  of  tuberculin  treatment 

anTmportant        (or   °^   anJ  other  treatment   in   pulmonary   tuberculosis). 
field  in  Whereas  the  pathological  findings  had  to  be  determined  at 

pulmonary 

tuberculosis,  autopsy  and  therefore  had  a  more  or  less  theoretical  bearing 
upon  the  results  of  tuberculin  treatment  ;as  compared  with 
generally  used,  other  treatments,  the  findings  as  shown  by  X-ray  examina- 
tions are  applicable  to  all  stages  of  the  disease.  In  these 
stages  are  included  the  more  important  class  of  cases  that 
come  under  the  arrested  or  healed  conditions. 

Important  contributions  to  the  X-ray   studies   of  lung 
structure,  such  as  come  from  Kennon  Dunham  and  others, 
Roentgen-  by  which  we  may  determine  the  method  of  healing  and  the 

nndingsCare  progress  of  healing  of  the  tubercular  processes  in  the  lung, 
of  great  aid  will  become  the  greatest  aid  to  the  wider  adoption  of  tuber- 
culin in  the  treatment  of  pulmonary  tuberculosis.  Although 
this  matter  is  yet  too  new  to  allow  definite  conclusions,  it 
merits  the  attention  which  I  wish  to  draw  to  it  at  this  time. 
My  personal  experience  has  made  me  most  enthusiastic. 
I  would  no  more  think  of  neglecting  an  X-ray  examination 
of  the  chest,  both  at  the  beginning  and  at  the  conclusion  of 
tuberculin  treatment,  than  I  would  treat  a  patient  with 


in  prognosis. 


FIG.  37. — Radiograph ic  picture  of  the  lungs  of  the  same  patient, 
whose  temperature  chart  is  here  reproduced  (Fig.  31,  page  143). 

The  lesions  in  the  lungs  follower!  several  extensive  operations  for 
tubercular  glands  of  the  neck.  The  last  operation  extended  into  the 
supraclavicular  space  almost  exposing  the  pleura  over  the  apex  of  the 
lung.  As  may  be  seen  in  the  above  X-ray  photograph,  the  lung  on  the 
same  side  (right)  is  infiltrated  and  clouded  throughout  the  upper  two- 
thirds  of  its  extent.  The  left  lung  seems  clear. 


PULMONAEY   TuBEBCULOSIS  131 

tuberculin  without  a  temperature  record.  I  have  included 
Figures  35,  36,  and  37  to  emphasize  my  purpose  in  calling 
attention  to  this  subject.  Not  only  are  such  demonstrations 
as  shown  in  these  illustrations  helpful  and  gratifying  to  the 
physician,  but  the  psychological  effect  on  the  patient  alone 
merits  the  trouble  and  expense  that  an  X-ray  photograph 
may  entail. 


CHAPTER  VII 
MISCELLANEOUS  TUBERCULAK  CONDITIONS 

There  are  very  few  instances  of  tubercular  infections, 
aside  from  those  we  have  described  in  the  foregoing  chapters, 
which  are  not  complications  or  extensions  of  the  more  impor- 
tant processes  we  have  already  described.  However,  since 
few  of  these  processes  may  exist  alone  or  are  so  prominent 
when  they  come  to  our  notice — the  original  process  having 
become  arrested — special  attention  must  be  called  to  their 
treatment.  The  following  are  the  conditions  which  need 
special  mention. 

Tuberculosis  of  the  Pleura 

in  acute  The  tubercular  infection  of  the  pleura  exists  mostly  as 

isbMt'to"  a  complication  of  pulmonary  tuberculosis,  and  need  not  be 

discontinue         considered,  as  far  as  tuberculin  treatment  is  concerned,  apart 

the  tuberculin  . 

treatment  from  the  pulmonary  process.     It  is  only  necessary  to  men- 

tion at  this  point  that  when  pleurisy  in  an  acute  form,  with 

symptoms  *  r  </  i 

are  over.  temperature,  suddenly  complicates  pulmonary  tuberculosis, 

it  is  best  to  wait  for  the  subsistence  of  the  acute  symptoms 
and  the  temperature  before  specific  treatment  is  begun.  And 
when  it  occurs  as  a  result  of  an  acute  infection,  such  as 
influenza,  etc.,  during  tuberculin  treatment,  it  is  best  to 
discontinue  the  inoculations  until  the  acute  symptoms  are 
over. 

The  so-called  idiopathic  pleurisy  is  getting  <to  be  recog- 
idiopathic  nized  more  and  more  as  a  complication  of  an  undiscovered 

pUurTsVrareiy     or  ^w\\,  pulmonary  tubercular  process.     So  frequently  has 
exists— hence       pulmonary   tuberculosis  appeared  in   a  patient  some  time 

it  should  . 

always  be  after  an  attack  of  the  so-called  idiopathic  pleurisy  that  most 

pu'mona"         authorities  are  now  recognizing  idiopathic  pleurisy  as  tuber- 

lesion-  cular  in  nature,  and  secondary  to  a  pulmonary  lesion.    These 

facts,  when  once  appreciated,  make  the  indications  for  tuber- 


MISCELLANEOUS  TUBEKCULAK  CONDITIONS          133 

culin  therapy  in  pleurisy  a  great  deal  clearer.  Hence,  the 
tuberculin  treatment  of  pleurisy,  where  pulmonary  lesion 
cannot  be  discovered,  would  certainly  be  the  most  rational 
treatment,  as  it  implies  early  pulmonary  involvement.  • 

In  the  case  of  temperature  accompanying  pleurisy  as  in 
the  case  of  pleurisy  complicating  a  definite  pulmonary  lesion, 
it  is  best  to  wait  for  a  subsidence  of  temperature  before 
tuberculin  treatment  is  begun. 

The  beginning  and  conclusion  of  treatment  of  the  so- 
called  idiopathic  pleurisy  is  the  same  as  that  outlined  for 
incipient  pulmonary  tuberculosis. 

Tubercular  Peritonitis 

Tubercular  peritonitis   is   another  form  of  tuberculosis  Tubcrculin 

is  of  value 

which  cannot  be  said  to  be  primary  in  nature.    In  all  proba-  in  tubercular 
bility  it  is  most  frequently  an  extension  from  the  mesen- 


teric  glands.     The  value  of  specific  treatment  in  this  con-  source  of  the 

,  .    .  -  117  ,..  ,  infection  in 

dition  is  no  longer  doubted,  as  all  authorities,  who  report  cases  where 

on  the  use  of  tuberculin  in  peritoneal  tuberculosis,  agree  as  haapsabroumht 

to  its  therapeutic  value.    In  this  connection,  we  cannot  over-  about  a  cure, 

"look  the  favorable  effect  on  a  tubercular  process  in  the  peri-  a  cure  in 

tonem,  of  the  exposure  of  the  peritoneal  cavity  to  the  air  caseswhere 

laparotomy 

by  means  of  laparotomy.  The  effect  of  this  procedure  has  proved 
been  so  frequently  noted  that  we  cannot  doubt  its  effect. 
However,  a  great  many  cases  are  not  improved  and  some  even 
become  distinctly  worse  after  laparotomy  ;  and  in  these  cases, 
tuberculin  remains  the  only  means  of  effective  therapeusis. 
Again,  we  may  have  tubercular  peritonitis  complicating 
extensive  lesions  in  a  bone  and  joint,  lung,  and  wide-spread- 
ing glandular  involvements  where  laparotomy  would  be 
contra-indicated,  but  where  tuberculin  administered  for  the 
major  conditions  has  shown  a  marked  effect  in  the  peri- 
toneal condition.  Barring  such  cases  of  tubercular  peri- 
tonitis, which  are  discovered  only  through  laparotomy,  it  is 
simpler  and"  more  effective  to  treat  peritoneal  tuberculosis 
with  tuberculin. 


134 


TUBERCULIN  AND  VACCINE 


Example: 

Successful 

tuberculin 

therapy  in 

a  case  of 

repeated 

recurrence 

after 

laparotomy. 


Even  those  conditions  which  clear  up  after  laparotomy 
could  be  benefited  by  tuberculin,  by  reason  of  the  influence 
which  it  exerts  over  the  original  focus  of  the  disease.  The 
following  three  cases  will  illustrate  effectively  the  value  of 
tuberculin  in  peritoneal  tuberculosis.  The  first  represents 
the  type  of  case  that  recurs  in  spite  of  laparotomy.  The 
second  illustrates  the  value  of  tuberculin  in  extensive  peri- 
toneal involvement  with  ;an  extension  of  the  tubercular  pro- 
cess following  laparotomy.  It  proves  the  conclusion  that 
even  if  the  local  peritoneal  region  is  improved  as  a  result  of 
the  laparotomy,  the  tubercular  infection  as  a  constitutional 
disease  still  persists  and  may  progress  unfavorably.  The 
third  shows  the  value  of  tuberculin  in  peritoneal  involve- 
ment, including  involvement  of  the  stomach  wall  and  intes- 
tines, with  extensive  constrictions  and  angulations  which 
could  not  all  have  gotten  well  by  laparotomy  alone,  even  if 
the  laparotomy  which  was  attempted  before  the  tuberculin 
treatment  had  succeeded. 

CASE  I.  A  full  history  of  this  case  may  be  found  in 
the  chapter  on  Treatment  of  Glandular  Tuberculosis,  page 
76.  It  shows  a  patient  on  whom  a  laparotomy  was  per- 
formed for  tubercular  peritonitis,  and  in  spite  of  the  ex- 
posure of  the  peritoneal  cavity  to  the  sun  and  air,  the  peri- 
toneum did  not  recover  from  the  tubercular  process.  The 
chronic  symptoms  continued  through,  a  period  of  two  years, 
finally  culminating  in  acute  peritonitis,  with  tubercular 
ulcerations  of  the  appendix.  Even  after  the  final  laparo- 
tomy, the  signs  of  chronic  peritonitis  continued  until  tuber- 
culin was  administered. 

CASE  II.  A  little  girl,  six  years  of  age,  had  a  negative 
family  history.  She  lived  in  a  region  where  the  milk  supply 
was  found  to  be  from  a  tubercular  herd.  Hers  was  a  case 
of  malnutrition  from  the  beginning.  Until  she  was  four 
and  a  half  months  old,  she  did  not  gain  in  weight  at  all. 
At  the  age  of  three  she  began  to  be  fussy  and  whiny.  She  had 
a  poor  appetite,  and  was  always  too  tired  to  play.  She 


MISCELLANEOUS  TUBERCULAR  CONDITIONS          135 

< 
grew  worse   and  had  a  temperature  rise  every  night,   and  Example: 

also  night  cries.      The  doctor  Avho  examined  her   found   a  with  a 
mass  in  the  region  of  the  appendix.     She  was  taken  to  the  complete 

disappearance 

hospital  for  appendectomy.     At  the  operation  the  appendix  ofthe 
which  was  removed  looked  normal,  but  a  mass  of  enlarged   peritonitis  but 
glands  was  discovered  in  the  retrocolic  region.    Her  recovery  a°  exTe'nsiJn 
from  this  operation  was  slow.     Soon  after  there  was  a  notice-  of  the  process 

elsewhere — 

able  enlargement  of  the  glands  of  the  neck,  both  cervical  requiring 

i  rvimi  T  i     •       i     tuberculin 

regions  being  anected.  luberculm  treatment  was  advised  therapy, 
and  carried  out  according  to  my  technic.  Two  months 
after  the  beginning  of  treatment  the  child's  weight  was 
34  pounds.  This  was  a  considerable  increase  over  her 
weight  at  the  beginning  of  treatment,  the  definite  amount 
of  which  was  not  noted.  She  responded  to  the  tuberculin 
treatment  from  the  beginning,  and  by  the  time  the  conclu- 
sion of  the  treatment  was  reached,  she  had  gained  fourteen 
pounds  more.  The  tubercular  glands  in  the  neck  and  the 
abdominal  symptoms  entirely  disappeared. 

CASE  III.  A  girl,  nineteen  years  old,  came  frequently  Example: 
to  my  clinic  with  a  little  nephew  who  was  being  treated  for  tube'cuiin 
wide-spread  tubercular  lesions.  At  one  of  the  visits  she  therapyin 

general 

asked  whether  she  could,  get  any  help  for  herself,  and  apolo-  peritonitis 

gized  for  speaking  of  herself  because  she  was  not  a  tuber-  ™,v0ivementVC 

cular    case.      I    became    interested    in    her    condition,    and  ofthegastro- 

thought  I  would  establish  a  diagnosis  and  then  direct  her  tract— where 

for  proper  treatment.  laparotomy 

was  impossible. 

She  had  always  been  healthy  except  that  her  menstrual 
periods  had  never  become  established  on  a  normal  basis. 
Her  menstruation  was  scant,  and  came  at  long  intervals  the 
first  few  years,  and  disappeared  entirely  for  three  years  pre- 
vious to  this  consultation.  Her  chief  complaint  was  con- 
stant vomiting — not  a  day  for  two  years  was  she  free  from 
vomiting,  with  general  pains  in  the  whole  abdomen  and  fre- 
quent attacks  of  cramps.  The  whole  complexity  of  symp- 
toms as  she  presented  them,  seemed  to  point  to  pyloric  ob- 
struction. There  was  no  history  of  hemoptysis,  but  the 


TUBERCULIN  AXD  VACCINE 

patient  had  lost  a  great  deal  of  weight  in  the  last  two  years. 
An  X-ray  study  of  her  gastro-intestinal  tract  revealed  a 
typical  hour-glass  stomach.  (Fig.  38.)  On  palpation  I 
found  that  the  lower  half  of  the  abdomen  seemed  to  be  filled 
with  a  hard  tumor,  reaching  to  about  one  finger's  breadth 
above  the  umbilicus.  A  preoperative  diagnosis  was,  "  hour- 
glass constriction  of  the  stomach  due  to  ulceration,'  and  a 
large  fibroid  tumor  of  the  uterus." 

Under  general  anesthesia,  laparotomy  was  performed 
with  a  right  median  incision  reaching  from  the  ensiform 
cartilage  to  the  umbilicus,  in  order  to  first  reach  the 
obstruction  and  to  relieve  it  by  gastro-enterostomy  if  neces- 
sary. The  abdominal  cavity  was  never  reached.  Layer 
after  layer  was  cut  through — there  seemed  to  be  no  end  to 
the  layers  of  peritoneum.  The  attempt  had  to  be  given  up. 
The  mass  of  membraneous  tissue  seemed  now  to  be  intimately 
connected  with  the  bowel  omentum  and  stomach,  so  that 
entrance  was  made  impossible.  It  was  decided  to  remove 
at  least  the  tumor,  and  ;a  second  incision  was  made  below  the 
umbilicus.  The  skin  and  facia  were  incised,  and  one  rectus 
muscle  pulled  to  one  side.  Instead  of  peritoneum,  a  layer 
of  cartilage  was  discovered — the  peritoneum  seemed  to  have 
been  converted  into  cartilage.  The  tubercular  nature  of  the 
peritoneum  became  apparent,  and  so  the  attempt  to  enter 
the  peritoneal  cavity  was  abandoned.  Although  I  was  fully 
conscious  of  the  beneficial  results  that  would  'be  brought 
about  by  opening  the  tubercular  peritoneum,  it  was  decided 
not  to  do  so  in  this  case  for  fear  of  an  eventual  inability  to 
close  the  peritoneum. 

The  patient  made  an  uneventful  recovery  from  the 
surgical  interference,  and  two  weeks  later  was  put  on  tuber- 
culin treatment.  After  the  ninth  inoculation,  improvement 
in  the  symptoms  began.  The  vomiting  spells  became  less 
and  less  frequent.  Treatment  was  begun  with  the  fourth 
dilution  and  by  the  ,time  the  second  dilution  was  reached, 
the  vomiting  and  pain  disappeared  entirely.  The  patient 


FIG.  38. — X-ray  photograph  of  the  stomach,  showing  hour-glass  con- 
striction due  to  tubercular  ulcerations  and  adhesions.  The  symptoms 
due  to  the  condition  were  all  relieved  by  tuberculin  treatment.  (See 
case  III,  page  138.) 


MISCELLANEOUS  TUBEKCULAK  CONDITIONS          137 

had  gained  about  eleven  pounds  in  weight,  and  strange  as  it 
may  seem,  the  hardness  of  the  abdominal  wall,  which  was 
thought  to  be  a  fibroid  and  was  found  to  be  due  to  the  car- 
tilagenous  peritoneum,  began  to  soften.  At  the  end  of  treat- 
ment with  tuberculin,  the  abdominal  wall  felt  entirely 
normal,  and  the  patient  is  now  in  apparent  perfect  health. 
Extensive  accumulation  of  fluid  should  always  be  with- 
drawn by  small  incision  or  puncture  or  aspiration,  whether 
it  occurs  immediately  before  the  tuberculin  treatment  is 
begun,  or  whether  it  occurs  during  tuberculin  treatment. 
A  course  of  OT,  beginning  with  the  fourth  dilution — and 
in  very  young  children  with  the  fifth  dilution — is  usually 
sufficient  to  cure  a  case  of  peritoneal  tuberculosis.  We  may 
conclude  the  treatment  with  Bacillary  Emulsion  or  not,  as 
the  case  may  be.  That  may  be  left  to  the  discretion  of  the 
physician.  However,  if  there  is  an  evident  focus  from 
which  the  infection  came,  it  is  best  to  conclude  the  course 
of  treatment  with  Bacillary  Emulsion. 

Tuberculosis  of  the  Eye 

The  effect  of  tuberculin  in  tubercular  involvement  of 
the  eye  was  responsible  for  my  early  enthusiasm  for  the 
value  of  tuberculin  in  general.  *  Tfo  quote  from  Bandelier 
and  Eoepke,  "  Tuberculin  has  brought  about  such  triumphs  Tuberculin  is 
in  ophthalmic  practice  as  to  call  increasing  attention  to  spe-  the  therapy 

_  r         par  excellence 

cific  treatment,  and  in  this  field  a  considerable  contribution  in  any 
was  made   toward?   rescuing  the  reputation  of  tuberculin.   Involvement 
The  surprising  cure  of  the  severest  forms  of  ocular  tuber-  oftheeye- 
culosis,  vision  being  retained  without  the  assistance  of  any 
other  therapeutic  measure,  is  in  fact  so  striking  as  to  exert 
a  healing  effect  also  on  the  blindness  of  the  opponents  of 
tuberculin" 

But  even  here  a  measure  of  care  must  be  exercised  in 
the  tuberculin  administration.  As  universal  as  the  bene- 
ficial effects  of  tuberculin  in  ocular  tuberculosis  have  been 
(see  the  large  amount  of  literature  on  the  subject),  bad 


favorable 
results  even 
:=  ocular 

tuberculosis 


10S  TUBERCULIN  AXD  VACCHCE 

results  may  nevertheless  be  produced  with  a  faulty  technic. 
The  following  is  a  good  example  of  the  ineffectiveness  of 
tuberculin  treatment  when  administered  by  too  slow  a 
technic,  even  though  the  patient  was  treated  in  a  sanatorium 
which  was  the  pioneer  institution  for  the  use  of  tuberculin 
in  this  country. 

A  young  man,  twenty-five  years  of  age,  at  first  had  kera- 
titis  in  one  eye,  which  soon  after  spread  to  the  other  eye, 
Exa=?:e:  He  was  treated  by  one  of  the  most  prominent  oculists  in 

Xew  York  for  a  number  of  years.  Owing  to  the  stubborn- 
ness of  the  lesion  the  patient  was  sent  to  Saranac  Lake,  in 
the  Adirondack  Mountains,  Xew  York,  where  he  was  treated 
with  tuberculin  over  a  period  of  two  years.  In  spite  of 
this  treatment,  his  condition  grew  worse,  so  that  by  the 
rime  he  returned  to  Xew  York  City  he  had  retained  but 
ten  per  cent,  of  his  field  of  vision.  The  oculist  who  had  a 
prejudice  against  tuberculin  previous  to  the  patient's  visit 
to  the  Adirondacks,  had  his  opinion  strengthened  by  the 
failure  of  the  tuberculin  in  this  case. 

It  was  therefore  through  a  special  circumstance  that  the 
patient  came  to  my  clinic  in  the  Xew  York  Polyclinic  Hos- 
piral  for  treatment.  He  brought  with  him  an  accurate  chart 
of  the  tuberculin  treatment  which  he  had  received  at  the 
Adirondack  sanatarinm.  It  showed  treatment  with  Bacil- 
lary  Emulsion — the  dosage  so  minute,  that  if  anything,  it 
would  have  encouraged  an  increase  in  hypersusceptibility. 
I  commenced  treatment  with  the  fourth  dilution  of  OT. 
A  mild  reaction  occurred  after  the  tenth  inoculation.  The 
improvement  in  his  tubercular  condition  was  so  marked  that 
a  tier  two  months  of  treatment  he  dared  to  tell  the  oculist 
that  he  was  being  treated  in  my  clinic — a  thing  he  was  keep- 
ing secret  lest  he  would  lose  the  friendship  and  treatment  of 
the  oculist,  whom  I  encouraged  him  to  visit  regularly  for 
the  local  treatment.  By  the  time  we  concluded  treatment 
with  tuberculin,  his  field  of  vision  had  increased  to  seventy 
fer  cent, — seven  times  the  amount  of  vision  that  he  had  at 


TlTBEECITLAB    flll»  IMTl^MRl  139 


the  beginning  of  tuberculin  treatment.  Both  through  the 
constitutional  improvement  due  to  tuberculin,  and  through 
the  mental  exhilaration,  his  general  i  mpifff  fi^K**!  kept  pace 
with  the  improvement  in  the  local  condition,  His  tri- 
monthly  tests  proved  negative  and  he  is  now  discharged  eared. 
The  following  three  points,  brought  out  by  this  history, 
more  than  emphasize  the  fabilj  of  the  premise  that  governs 
the  prejudice  against  tuberculin.  They  also  show  how  easily 
other  elements  and  not  the  tuberculin  itself  may  in  haul  ft 

*  mf 

such  prejudice: 

First,  the  oculist,  who  is  now  converted  to  a  favorable 
attitude  towards  tuberculin,  has  acknowledged  that  his  pre- 
judice was  based  on  nothing  but  hearsay,  and  that  he  had 
never  had  a  personal  experience  with  its  use. 

Second,  the  tuberculin  treatment  at  first  failed  in  this 
case  —  not  because  of  an  inefficiencv  of  tuberculin.  —  but 
because  of  a  f  aultv  technie  in  its  •«lmiuu4»nt  »o"  r 

Third,  the  publication  of  such  negative  results  from  the 
tuberculin  treatment,  coming  from  such  an  authoritative 
source  as  that  particular  sanitarium,  does  more  to  prevent 
the  wider  adoption  of  the  use  of  tuberculin  than  any  other 
agency. 

The  beginning  treatment  of  eye  tuberculosis  where  the 
involvement  is  acute  and  extends  to  the  interior  of  the  eye- 
ball should  be  with  the  fifth  dilution.  But  where  the  disease 
is  limited  to  the  conjunctiva,,  cornea,,  iris  and  so  on.  0.10  c-c, 
of  the  fourth  dilution  is  not  too  large  a  beginning  dose.  It 
is  best  to  conclude  the  treatment  with  Bacillary  Emulsion  as 
shown  in  Chart  III. 

Tuberculosis  of  the  Ear 

The  literature  is  very  meager  as  to  the  effect  of  tuber- 
culin in  tuberculosis  of  the  ear.  3Iy  experience  consists  of 
ear  involvements  in  two  cases  of  pulmonary  tuberculosis, 
and  in  one  case  of  renal  tuberculosis.  In  all  three,  die  ear 
conditions  cleared  up  during  the  tuberculin  treatment. 


140 


TUBERCULIN  AND  VACCINE 


The  local 
treatment  of 
lupus  can 
prove  of  value 
only  when 
combined 
with  the 
constitutional 
tuberculin 
treatment. 


The  reactive 
method  of 
tuberculin 
therapy  is 
best  in  lupus. 


Tuberculosis  of  the  Skin 

Lupus  offers  one  of  the  most  fertile  fields  for  the  use  of 
tuberculin.  The  skin  specialists  have  long  since  noticed  the 
absolute  necessity  for  constitutional  treatment  in  all  refrac- 
tory skin  conditions.  Can  there  be  a  more  perfectly  adapted 
constitutional  treatment  than  tuberculin  for  the  skin  lesion 
which  is  tubercular  in  nature?  Tuberculin  will  overcome 
deep-seated  induration;  and  in  those  cases  where  the  lupus 
spot  does  not  entirely  disappear  after  the  tuberculin  treat- 
ment, the  various  forms  of  local  treatment  such  ,as  pyrogallic 
acid,  Finsen  treatment,  etc.,  will  find  their  proper  places. 
As  Wolters  puts  it,  "  The  exciting  cause  of  the  disease  seems 
to  be  enticed  from  the  body  and  given  out  by  exudation,  and 
is  then  destroyed  by  pyrogallic  acid."  In  lupus  of  the 
mucus  membranes  where  these  local  treatments  are  impos- 
sible, or  of  no  value,  tuberculin  will  show  its  best  effect. 

Since  the  large  percentage  of  lupus  occurs  in  individuals 
suffering  from  other  forms  of  tuberculosis,  especially  that 
of  the  lung,  we  have  to  divide  the  tuberculin  treatment  into 
two  distinct  methods — the  reactive,  which  applies  to  lupus 
appearing  alone — and  the  method  of  tuberculin  treatment, 
applying  to  the  various  forms  of  the  infection  which  the 
lupus  complicated.  In  other  words,  if  lupus  appears  in 
combination  with,  or  as  an  extension  of  tuberculosis  of  the 
glands  or  of  the  lungs, — the  tuberculin  treatment  will  apply 
to  the  glands  or  to  the  lungs,  and  the  lupus  condition  will 
take  care  of  itself  as  a  result  of  the  treatment  of  the  other 
condition.  The  treatment,  however,  of  primary  lupus  is 
entirely  different.  Here  the  reactive  method  will  show  the 
best  result.  The'  severe  focal  reaction  that  takes  place  with 
the  constitutional  reaction  will  help  to  throw  off  the  diseased 
tissue;  and  as  a  result,  scarring  over  and  healing  will  soon 
take  place.  Beginning  the  treatment  with  0.10  c.c.  of  the 
second  dilution,  this  dose  is  increased,  and  the  increase  is 
increased  at  every  inoculation,  instead  of  at  every  other 
inoculation,  until  a  constitutional  reaction  occurs.  The  dose 


MISCELLANEOUS  TUBEECULAR  CONDITIONS          141 

which  produced  the  constitutional  reaction  is  now  repeated 
until  it  no  longer  produces  a  constitutional  reaction.  The 
only  change  .we  make  as  a  result  of  these  reactions  is  to 
make  the  interval  a  week,  instead  -of  bi-weekly,  as  before 
the  constitutional  reaction.  After  the  dose  no  longer  pro- 
duces a  reaction,  we  again  inoculate  bi-weekly,  increasing 
the  dose  as  at  the  beginning  of  the  treatment.  Should  these 
constitutional  reactions  affect  the  patient  too  severely,  the 
dosage  should  be  increased  more  slowly  after  the  constitu- 
tional reaction  by  following  the  same  indications  here  as 
we  do  in  the  treatment  of  the  other  conditions.  (See  Table 
II.)  The  conclusion  of  treatment  must  be  followed  very 
carefully  by  the  rapid  Bacillary  ,Emulsion  inoculation. 
(Table  III.)  The  local  treatment  can  be  undertaken  simul- 
taneously with  the  Bacillary  Emulsion  inoculations. 

The  local  treatment  of  lupus  with  tuberculin,  whether  Theiocai 

.......  ..  .  ..  treatment  of 

by  inoculation  into  the  lupus  spot  or  by  inunctions  of  various  iupus  with 
other  ways,  cannot  be  recommended.    As  tuberculin  depends  *»b*fai1** 1S 

of  no  value. 

upon  its  action  on  a  constitutional  effect,  the  favorable  re- 
sults produced  by  this  method  in  the  few  cases  that  are 
reported  in  the  literature  may  have  (been  brought  about  by 
a  sufficient  absorption  of  tuberculin  into  the  circulation,  that 
amount  accidentally  being  in  sufficient  quantity  to  produce 
favorable  results.  As  a  routine,  it  cannot  be  recommended 
for  the  same  reason  that  the  oral  Sadministration  of  tuber- 
culin cannot  be  recommended — it  lacks  a  most  important 
essential  in  tuberculin  treatment — exactness  of  dosage. 


CHAPTER  VIII 
SPECIAL  CONDITIONS 

In  concluding  the  section  on  tuberculin  treatment,  I 
wish  to  call  attention  to  a  few  special  conditions  and  irregu- 
larities that  may  arise  during  the  treatment  of  any  tuber- 
cular condition  with  tuberculin. 

• 

Constitutional  Reaction 

A  proper  At  times  it  is  important  to  determine  whether  a  tempera- 

of^'risein*101       ture  ri&e  occurring  the  day  after  a  tuberculin  inoculation  is 
temperature         (jue  to  a  constitutional  reaction,  or  whether  the  rise  is  due 

due  to  a 

constitutional       to  factors  other  than  the  tuberculin.     Any  condition  that 

could  bring  about  a  temperature  rise  could  just  as  easilv  at- 

temperature         f^k  an  individual  the  day  after  a  tuberculin  inoculation 

due  to  any  '.  . 

other  cause  as  at  any  other  time.  It  has  been  my  experience  that  on 
many  occasions  a  rise  of  temperature  to  101°  F.  or  higher, 
which  occurred  on  the  day  after  the  last  inoculation  was 
found  to  be  due  to  an  intestinal  derangement  following  a 
dietary  indiscretion,  a  fact  that  was  determined  only  after 
careful  questioning  of  the  patient.  The  fact  that  there  was 
no  local  reaction  and  the  fact  that  the  temperature  persisted 
longer  than  one  day,  or  either  of  these  facts  alone,  was  suffi- 
cient to  arouse  my  suspicion  as  to  the  true  cause  of  the  tem- 
perature. If  questioning  the  J>atient  does  not  definitely 
clear  up  the  doubt  as  to  the  source  of  the  temperature,  we 
may  resort  to  the  expedient  of  administering  the  same  dose 
a  second  time.  ;This  will  have  a  two-fold  advantage.  In 
the  first  place  it  will  verify  the  fact  that  the  temperature 
rise  was  a  reaction  by  producing  a  temperature  again.  And 
in'  the  second  place,  if  the  second  inoculation  will  produce 
no  temperature  rise,  it  will  avoid  a  reduction  in  dose  and  a 
slowing  of  the  increases.  Colds,  mixed  infection  and  many 
other  conditions  coming  after  a  tuberculin  inoculation  may 


SPECIAL  CONDITIONS 


143 


144 


TUBERCULIN  AND  VACCINE 


The  occurrence 
of  tuberculin 
intolerance 
may  be 
overcome  by 
a  change  in 
the  variety  of 
tuberculin 
used. 


The  more 
concentrated 
doses  of  BE 
are  apt  to 
produce 
abscess 
formation 
at  the  site  of 
inoculation. 


simulate  a  constitutional  reaction,  but  must  be  carefully 
recognized  in  order  not  to  affect  the  tuberculin  treatment. 
(Fig.  39.) 

Tuberculin  Intolerance 

Occasionally  it  may  happen  during  the  administration 
of  OT  that  after  a  constitutional  reaction,  any  dose  of  OT, 
however  small,  will  produce  a  reaction.  This  phenomenon 
is  distinct  from  reactions  caused  by  increased  hypersuscepti- 
bility;  for  whereas,  after  an  increased  hypersusceptibility 
a  change  in  the  variety  of  tuberculin  will  make  no  difference 
as  to  the  production  of  a  reaction,  provided  a  corresponding 
amount  is  used,  in  the  case  of  intolerance  a  change  of  tuber- 
culin will  stop  the  reactions,  even  if  a  much  larger  dose  is 
used.  It  is  therefore  necessary  in  case  of  a  sudden  appear- 
ance of  tuberculin  intolerance,  to  change  the  variety  of  the 
tuberculin  used.  For  example,  if  after  a  few  months  of 
treatment  with  OT,  a  tubefculin  intolerance  arises,  and  if 
at  that  time  the  second  dilution  was  being  administered,  OT 
is  discarded  at  this  point,  and  a  third  dilution  of  BE  sub- 
stituted. The  treatment  is  then  continued  with  the  BE  in 
the  same  manner  as  it  would  have  been  administered  if  OT 
were  still  being  used.  On  reaching  the  first  dilution  of 
BE,  the  treatment  is  concluded  in  the  usual  manner  as  per 
Dose  Table  III,  depending  upon  the  tubercular  process 
under  treatment. 

Abscess  Formation 

It  was  observed  early,  that  the  tubercle  bacillus  cannot  be 
absorbed  from  the  subcutaneous  tissue  when  administered 
in  the  form  of  a  vaccine,  and  when  so  administered  lead  to 
abscess  formation.  Thus  it  became  necessary  to  pulverize 
the  bacillary  bodies  in  the  manufacture  of  BE.  However, 
it  even  now  frequently  happens  that  after  the  administration 
of  BE  pure,  suppuration  takes  place  around  the  point  of 
inoculation,  with  final  breaking  down  of  the  tissues.  The 
abscess  thus  formed  is  more  in  the  nature  of  a  cold  abscess, 


SPECIAL  CONDITIONS  145 

as  repeated  cultures  of  the  pussy  looking  fluid  that  escapes 
have  failed  to  produce  any  growth.  As  such  abscesses  break 
down  by  virtue  of  a  tryptic  digestion,  healing  takes  place 
immediately  upon  the  emptying  of  the  abscess  cavity.  I 
have  found  that  diluting  the  dose  two  or  three  times  with 
normal  saline,  and  inoculating  the  amount  in  two  or  three 
different  places  at  one  time,  will  avoid  abscess  formation. 
For  example,  if  0.20  c.c.  of  pure  BE  is  the  amount  to  be 
inoculated,  0.40  c.c.  of  normal  saline  can  be  drawn  into  the 
syringe  with  the  0.20  c.c.  of  pure  BE,  the  syringe  thor- 
oughly shaken,  and  about  0.20  c.c.  of  the  contents  inoculated 
in  three  different  places,  as  far  apart  on  the  arm  as  possible. 

Autoinoculation 

I  wish  to  draw  special  attention  to  autoinoculation,  both  The  physical 
in  order  to  distinguish  it  from  tuberculin  intolerance,  and   autoinoculation 
bv  way  of  warning  against  its  artificial  induction.     Auto-  sho?]dbe 

«/  t>  avoided 

inoculation  may  be  brought  about  by  any  means  which  forces  as  far  as 
an  undue  amount  of  the  tubercular  material  into  the  circu- 
lation from  the  localized  tubercular  process.  An  undue 
amount  of  breathing  exercise  may  bring  about  an  autoin- 
oculation from  a  pulmonary  lesion.  The  use  of  a  joint 
which  is  the  seat  of  a  lesion  may  force  tubercle  bacilli  or 
the  product  of  tubercle  bacilli  into  the  circulation.  Massage 
over  a  tubercular  area  may  bring  about  the  same  result. 
This  is  especially  true  of  knee  joint  disease. 

The  following  is  an  interesting  example  of  autoinocula- 
tion :  A  man,  forty  years  old,  had  a  very  severe  active  lesion 
in  the  knee  joint.  After  nearly  a  year  in  the  hospital  under 
the  usual  orthopedic  treatment,  a  resection  of  the  knee  joint 
was  advised.  This  alarmed  the  patient,  who  insisted  on 
going  home.  After  he  had  been  at  home  for  several  months,  ^*ampl':  . 

'    The  production 

I  was  called  to  see  Mm.     I  found  him  wasted  and  pallid,  of  severe 

«,i      .'i  ,.  >i,i  -n  •         •  L  i       •  autoinoculation 

with  the  entire  right  leg  swollen  to  twice  its  natural  size.   through 

The  knee  was  inflamed  and  the  entire  adductor  region  was  massage 

•  i     i      °ver  tne 
a  mass  of  hard  induration.     The  pain,  especially  with  the  infected  area. 

10 


14(5  TUBERCULIN  AND  VACCINE 

slightest  movement,  was  agonizing.  The  least  motion  with 
his  toe,  the  shaking  of  the  bed  put  the  patient  into  a  quiver 
of  pain.  The  severest  ordeal  that  the  patient  had  to  go 
through  was  on  being  removed  to  the  hospital.  Four  months 
of  tuberculin  treatment  at  the  hospital  was  sufficient  to 
bring  about  a  quiescent  state  in  the  lesion, — the  surrounding 
induration,  pain  and  tenderness  disappearing, — so  that  we 
were  able  to  send  him  home  on  crutches.  The  tuberculin 
treatment  was  continued  at  his  home  by  one  of  my  associates. 
After  four  weeks  of  treatment  at  home,  and  after  several 
closes  of  the  first  dilution  had  been  administered,  a  reaction 
occurred,  which  was  unduly  violent,  temperature  reaching 
105°  F.  On  account  of  the  violence  of  the  reaction,  a  much 
greater  reduction  in  dose  was  made  than  is  customary  after 
a  reaction,  and  again  a  temperature  of  104°  F.  occurred  fol- 
lowing the  inoculation.  A  still  greater  reduction  in  the  dose 
was  made  after  the  second  reaction,  and  a  third  equally  vio- 
lent reaction  occurred.  A  dose  of  0.10  c.c.  of  the  fifth  dilu- 
tion was  administered  after  the  third  reaction,  but  still  a 
temperature  rise  to  105°  F.  occurred  following  this  dose. 
It  puzzled  the  attending  physician,  a  great  deal ;  he  called  me 
into  consultation.  An  examination  of  the  patient  disclosed 
nothing  that  would  account  for  the  increase  of  the  hypersus- 
ceptibility.  The  local  condition,  in  spite  of  the  various  reac- 
tions, had  not  become  worse.  I  closely  questioned  the  patient, 
insisting  on  an  account  of  h,is  actions  forgery  moment  of  the 
day,  from  Jbis  getting  up  in  the  morning  to  his  going  to  sleep 
at  night.  After  a  great  deal  of  cross  questioning,  the  fact 
was  brought  out  that  on  the  same  day  that  the  doctor  called 
to  give  him  his  tuberculin  treatment,  ja  friend  of  his,  who  is 
a  masseur  by  profession,  called  on  him,  and  administered  a 
body  massage,  with  particular  emphasis  on  the  diseased  knee. 
This  was  done  in  a  friendly  spirit,  and  "  in  order  to  improve 
his  circulation."  That  it  might  produce  harm  was  so  remote 
from  the  patient's  mind  that  he  neither  mentioned  these 
massages  to  the  physician  treating  him,  nor  to  me.  The  mas- 


SPECIAL  CONDITIONS  147 

sages  were  discontinued,  and  upon  lay  advice  0.10  c.c.  of 
the  second  dilution  —  a  thousand  times  the  dose  which  sup- 
posedly produced  the  last  reaction  —  was  administered  with- 
out the  least  sign  of  a  reaction.  In  the  next"  four  or  five 
treatments  the  same  amount  was  reached  that  was  adminis- 
tered when  reactions  .began.  From  there  on  the  treatments 
were  continued  uninterruptedly.  In  about  a  month  from 
that  time  he  came  to  the  Out-Patient  Department  of  the 
Xew  York  Polyclinic  Hospital,  for  conclusion  of  treatment, 
making  his  bi-weekly  trips  without  any  trouble.  In  less 
than  a  year  from  the  beginning  treatment,  he  returned  to  his 
occupation  as  baker. 

The  only  way  to  overcome  autoinoculation  is  by  reducing 
the  activity  of  the  part  affected.  In  febrile  pulmonary  tuber- 
culosis, rest  in  bed  will  reduce  temperature  if  it  is  caused  by 
autoinoculation. 

Tri-monthly  Tests 

To  one  who  has  had  a  large  experience  in  the  tuberculin  Periodi 
treatment  of  tubercular  conditions,  the  following  important 


fact  is  evident:  any  recurrence  of  the  process  after  it  has  tests  after  the 
been  arrested  during  the  tuberculin  treatment  is  accompanied  tuberculin 
by  a  recurrence  of  hypersusceptibility.  It  occurred  to  me 
some  years  ago  to  follow  up  the  treatment  of  a  series  of 
patients  after  the  conclusion  of  tuberculin  treatment  to  de- 
termine at  intervals  by  a  tuberculin  test  'any  tendency  for 
the  recurrence  of  hypersusceptibility.  I  thus  found  that 
the  recurrence  of  hypersusceptibility  precedes  the  recurrence 
of  a  tubercular  lesion.  (A  series  of  tuberculin  inoculations 
was  instituted  in  every  case  that  showed  a  recurrence  of 
hypersusceptibility.  As  a  result  no  recurrence  of  a  tuber- 
cular lesion  took  place  in  the  last  few  years  that  these  tests 
were  carried  out. 

The  systematic  tri-monthly  tests  were  adopted  as  a  con- 
sequence of  these  findings.  By  applying  tuberculin  test 
every  three  months,  for  two  years  following  the  conclusion 
of  tuberculin  treatment,  we  were  able  to  get  ahead  of  any 


148 


TUBERCULIN  AND  \'rACCiNE 


Appropriate 
tuberculin 
treatment 
to  overcome 
recurrence 
of  hypersus- 
ceptibility 
will  prevent 
a  recurrence 
of  the 
disease. 


Example: 
The  recurrence 
of  hypersus- 
ceptibility 
in  a  case 
clinically 
cured. 


possible  recurrence  in  all  cured  cases.  A  dose  consisting  of 
0.10  c.c.  of  the  first  dilution  of  OT  (0.01  c.c,  of  OT  pure) 
is  administered  as  a  test  in  all  cases  except  where  there  was 
a  definite  history  of  an  infectious  disease  having  attacked 
the  patient  between  the  conclusion  of  the  treatment  and 
this  test.  If  an  infectious  disease  did  intervene  the  divi- 
sional method  of  testing  should  be  adopted ;  that  is,  0.10  c.c. 
of  the  second  dilution  is  given  as  a  first  test;  0.50  c.c.  of  the 
second  dilution  forty-eight  hours  later;  and  then  0.10  c.c.  of 
the  first  dilution  as  a  final  test,  forty-eight  hours  after  the 
second  test. 

Should  any  of  the  tests  prove  by  a  constitutional  reaction 
that  hypersusceptibility  has  returned,  the  patient  should 
again  be  put  on  the  tuberculin  treatment,  beginning  the 
course  with  a  tenth  of  the  quantity  of  tuberculin  which 
caused  the  reaction,  and  concluding  in  the  same  manner  as 
in  the  original  course  of  treatment. 

The  following  cases  will  illustrate  the  importance  of  the 
tri-monthly  test  in  the  detection  of  recurring  hypersuscepti- 
bility, and  the  value  of  treatment  to  prevent  recurrence  of 
the  disease  where  the  test  is  positive. 

CASE  I.  A  young  man  twenty-four  years  of  age,  had 
a  negative  family  history,  with  the  exception  of  a  sister  who 
had  tubercular  adenitis.  His  past  history  showed  that  he 
had  had  measles  and  chicken  pox  some  time  before  he  was 
ten  years  old.  Otherwise  he  was  well  and  strong  until  five 
years  before  the  beginning  of  treatment.  At  that  time  he 
began  to  have  attacks  of  cramps  in  the  abdomen,  which  began 
at  the  pit  of  the  stomach,  radiating  and  finally  settling  in 
the  region  of  the  appendix.  Nausea  and  vomiting,  followed 
by  diarrhea,  would  frequently  accompany  these  attacks, 
which  recurred  every  three  or  four  months,  and  would  last 
from  one  to  four  days.  'On  account  of  the  absence  of  rigid- 
ity over  the  appendix,  a  definite  diagnosis  of  appendicitis 
was  not  made,  but  he  was  treated  for  "  stomach  trouble  and 
inflammation  of  the  bowels."  In  September,  1915,  an  attack 


SPECIAL  CONDITIONS  149 

occurred  which  was  more  severe  than  usual,  lasting  a  week. 
Another  attack  followed  in  October,  which  persisted  for  ten 
days.  At  this  time  an  operation  for  appendicitis  was  advised 
and  carried  out  in  the  early  part  of  November.  At  the 
operation  the  tubercular  nature  of  the  trouble  was  discov- 
ered. The  tubercular  process  existed  not  only  in  the  mesen- 
teric  glands,  but  also  in  the  pelvic,  peritoneal,  and  prostate 
glands.  Five  days  after  the  operation,  severe  pain  began 
in  the  rectum,  and  after  the  patient  had  been  kept  under  the 
influence  of  morphine  for  several  days  on  account  of  the 
severity  of  the  pain,  the  pain  suddenly  disappeared  on  the 
appearance  of  a  large  amount  of  pus  in  the  urine. 

After  a  stay  of  about  three  weeks  at  the  hospital,  he  was 
referred  to  me  for  tuberculin  treatment,  which  was  begun 
on  December  11,  1915,  and  ended  on  September  14,  1916. 
During  the  course  of  treatment  he  had  only  two  constitu- 
tional reactions.  His  weight  at  the  beginning  of  treatment 
was  148  pounds,  which  was  far  below  normal  weight  for  his 
height,  and  increased  to  175  pounds  at  the  conclusion  of 
treatment.  The  pus  in  the  urine,  and  the  pain  in  his  back 
and  rectum  disappeared.  Only  one  attack  of  abdominal  pain 
occurred  soon  after  beginning  the  tuberculin  treatment,  and 
has  never  since  recurred.  Six  months  after  the  institution 
of  tuberculin  treatment,  he  returned  to  his  occupation,  and 
has  kept  at  it  since. 

He  received  the  first  tri-monthly  test  in  December,  1916. 
The  dose  was  0.10  c.c.  of  the  first  dilution,  and  was  followed 
with  negative  results.  The  second  test  was  given  in  March, 
1917,  and  to  the  surprise  of  both  patient  and  myself,  there 
was  a  severe  constitutional  reaction,  the  temperature  rising 
to  101°  F.,  pain  in  the  abdomen  and  in  the  back  being  quite 
severe  during  the  rise  in  temperature.  This  patient  seemed 
to  have  so  thoroughly  gotten  over  his  disease  that  I  was  not 
at  all  insistent  about  his  coming  .for  the  tests.  But  as  he 
put  it,  "  the  dread  of  the  return  of  the  disease  was  so  strong 
that  he  would  not  miss  a  single  direction  given  him  during 


150  TUBERCULIN  AND  VACCINE 

treatment,"  and  so  he  came  punctually  for  the  test.  The 
reaction  which  followed  the  second  test  occurred  as  the 
result  of  0.10  c.c.  of  the  first  dilution.  His  treatment  was 
resumed  with  0.10  c.c.  of  the  second  dilution. 

Example:  CASE  II.     This  child,  a  five-year-old  girl,  whose  family 

cohered'8  history  is  negative,  was  three  years  old  before  it  was  dis- 

recun-ence          covered  that  she  had  tuberculosis  of  the  left  knee.     X-ray 

of  hypersus- 

ceptibiiity  findings  showed  a  mild  lesion  in  the  epiphysis  of  the  femur, 

afteTTiT8  with  some  erosion  of  the  posterior  surface  of  the  patella. 

infectious  After  wearing  a  cast  for  two  years,  tuberculin  treatment  was 

disease, 

followed  by  instituted  and  continued  without  interruption  until  a  dose 
o/thedisease  °^  ^.80  c>c-  °^  tne  ^rs^  dilution  of  BE  was  reached  in  Au- 
gust, 1915.  There  was  at  this  time  a  complete  functional 
cure.  The  child  seemed  in  perfect  health  and  was  discharged 
as  cured  by  the  physician  who  had  administered  the  tuber- 
culin according  to  the  technic  outlined  in  this  work.  On  ac- 
count of  the  seemingly  good  result  obtained,  the  doctor  did 
not  urge  upon  the  parents  the  continuation  of  the  treatment, 
nor  were  they  instructed  to  bring  the  child  for  the  tri- 
monthly  tests.  Six  months  after  the  last  dose  of  tuberculin 
the  child  took  sick  with  measles.  Two  or  three  weeks  later 
she  began  to  complain  of  pain  in  the  knee,  with  limitation 
of  motion,  and  there  was  a  temperature  (rectal)  rise  to 
101°  F.  daily.  In  this  case,  treatment  was  resumed  with 
the  third  dilution. 


SPECIAL  CONDITIONS 


151 


°l 

21 


OS 


0» 


3 

"C 


i  j]  qio 


152 


TUBERCULIN  AND  VACCINE 


PAET  III 
SPECIAL  TREATMENT 

CHAPTER  I 
INTRODUCTION 

Up  to  the  present  day.  most  of  the  work  done  with  tuber-  Tuberculin 

should  not  be 

culin  has  been  done  by  lung  specialists,  and  in  sanatoriums  employed  to 

where  the  hygienic  dietetic  treatment,  and  all  other  adjuncts  Of  other US 

of  tuberculin  treatment  have  been  followed  out  as  a  matter  ^"pe^c 

measures. 

of  course.  However,  in  the  teaching  of  tuberculin  treat- 
ment the  importance  of  these  measures  as  an  adjunct  to 
tuberculin  has  been  overlooked,  resulting  in  their  neglect 
when  tuberculin  was  given  a  trial. 

Since  this  work  is  calculated  to  emphasize  the  value  of  Tfh,ctctic 

*  ot  tuberculin 

tuberculin  in  surgical  tuberculosis,  the  use  of  tuberculin  is  specific 

would    be    doomed    to   failure,    in   the   large   majority    of  tubercular 

cases,  were  we  to  neglect  the  other  measures  which  are  "just  mfectl°n> 

and  not 

as  vital  in  bringing  about  a  cure.     We  must  bear  in  mind  against  the 

that  tuberculin  can  overcome  only  the  infection;  that  the  processes 

disease,  which  in  surgical  cases  has  persisted  for  years,  has  which  occur 

as  a  result 

left  its  traces  behind  in  the  form  of  pathological  changes;  of  the 

and  that  unless  we  apply  correct  measures  to  these  at  the  infection" 
same  time,  we  cannot  hope  to  produce  appreciable  results. 
To  the  patient,  it  is  just  the  same  whether  his  fistulas 

.  ,.  ,  The  consequent 

or  bone  cavities  are  kept  open  with  a  discharge  of  pus  due  processes  may 

to  the  streptococcus  or  staphylococcus,  or  whether  the  dis-  font'nuethe 

*     »  invahdism 

charge  is  due  to  the  tubercle  bacillus.    While  from  a  medical  after  the 

standpoint,  the  elimination  of  hypersusceptibility  with  tuber-  Of  the 

culin  is  already  of  great  advantage  to  the  patient — bv  check-  tubercular 

process. 

ing,  as  it  does,  the  further  spread  of  the  tubercular  process — 
still,  the  local  manifestations  of  mixed  infections  are  just  as 
troublesome  and  tend  as  much  to  invalidism  as  before. 


l.Vt 


TUBERCULIN  AND  VACCINE 


The  application 
of  orthopedics 
is  necessary 
to  bring  about 
good  results 
from  tuber- 
culin therapy. 


Tuberculin 
therapy  will 
act  as  a 
guide  to  the 
application 
of  orthopedic 
treatment. 


Surgical 
interference 
must  be 
limited  to  the 
conditions 
outside  of  the 
influence  of 
tuberculin. 


Aeain,   tuberculin  must  not  be  understood  to  take  the 

c?  / 

place  of  orthopedic  treatment,  for  the  deformity  is  not  caused 
by  tbe  tubercular  infection  itself,  but  by  the  results  of  the 
tubercular  process.  In  arresting  the  infection  with  tuber- 
culin we  do  not  correct  deformities  and  do  not  replace  de- 
stroyed joints  or  bones. 

At  the  same  time,  although  the  aim  of  orthopedic  treat- 
ment is  to  prevent  or  correct  deformity,  it  cannot  claim  to 
^top  the  infection.  And  all  orthopedic  appliances  can  be 
of  no  avail,  unless  during  their  application,  a  natural  resist- 
ance overcomes  the  infection.  Otherwise,  in  spite  of  the 
appliances,  even  under  the  best  of  circumstances,  the  recur-: 
rence  of  these  deformities  may  take  place. 

However,  the  combination  of  orthopedic  and  tuberculin 
therapy  is  ideal:  the  immunotherapy  to  limit  the  disease 
and  to  overcome  susceptibility,  the  ortho-therapy  to  prevent 
deformity.  The  tuberculin  will,  moreover,  act  as  a  guide  to 
the  limitation  of  orthopedic  treatment — it  will  be  unneces- 
«ary  to  order  the  cumbersome  appliances  to  be  worn  year 
after  year,  for  tuberculin  will  do  away  with  the  element  of 
"  guess,"  which  has  to  be  so  prominent  in  orthopedics.  For 
with  the  conviction  of  having  checked  the  infection  and  over- 
come the  susceptibility,  the  length  of  time  for  orthopedic 
application  can  be  gauged  more  accurately. 

The  same  holds  true  of  the  application  of  surgery  in 
tuberculosis.  Eliminating  the  danger  of  extension  of  the 
disease  by  overcoming  the  jsusceptibility  to  tuberculosis  be- 
fore surgical  interference,  will  not  only  reduce  to  a  minimum 
the  amount  of  surgery  required,  but  that  which  is  required 
can  be  done  with  greater  safety. 

Cicatrized  tubercular  glands  may  be  removed  under  local 
anesthesia,  with  the  most  conservative  incision,  whereas 
tubercular  glands  removed  without  a  previous  tuberculin 
treatment  very  frequently  recur  even  after  a  radical  opera- 


tion. 


Whether  tuberculin  treatment  is  necessary  to  make  other 


INTRODUCTION  155 

methods   of  treatment   efficient,   or  whether  other   methods   Tuberc"losis 

is  a  combina- 

are  needed  to  make  the  tuberculin  a  success,  the  fact  remains  tion  of 
that  a  combination  of  certain  methods  of  treatment  is  vastly   hence— a' 
superior  to  each  one  alone.  combined 

therapy  is 

We  have  also  advocates  of  bismuth  paste  in  tubercular  most  rational, 
cavities  and  abscesses.  There  is  110  doubt  that  in  isolated 
cases  we  have  good  results  from  the  use  of  bismuth  paste 
alone.  And  since  we  cannot  differentiate  between  the  cases 
which  should  have  bismuth  alone,  and  which  should  have 
tuberculin  alone,  why  not  avoid  failure  from  a  wrong 
choice  by  using  both,  in  all  cases  ?  There  is  no  doubt  that  the 
bismuth  acts  purely  mechanically  by  establishing  a  high  spe- 
cific gravity  in  the  cavity  or  fistula.  It  thus  prevents  nega- 
tive pressure,  which  is  the  cause  of  exudation  of  serum  and 
lymph,  the  accumulation  of  which  forms  the  best  culture 
medium  for  the  further  growth  of  bacteria  and  thus  con- 
tinues the  pathological  process  indefinitely.  So  by  the  use 
of  bismuth  paste,  we  overcome  a  prominent  ,f  actor  that  con- 
tinues the  subjective  symptoms  of  the  disease  which  is  be- 
yond the  province  of  the  mechanism  of  immunity. 

As  regards  the  application  of  hyperemia,  the  tuberculin 
therapy  is  again  of  inestimable  value.  Bier  reports  excel- 
lent results  with  hyperemia  alone,  and  since  the  part  of  the 
mechanism  of  the  immune  response  is  a  focal  reaction  con- 
sisting of  hyperemia,  the  introduction  of  Bier's  hyperemia 
may  be  of  great  value  during  the  course  of  tuberculin  treat- 
ment. In  fact,  in  isolated  cases,  it  may  provide  the  elements 
of  success  in  an  otherwise  stubborn  case.  There  might  have 
been  some  obstruction  to  circulation,  or  some  other  element 
which  may  have  prevented  focal  reaction ;  or  the  antibodies 
may  not  have  been  able  to  reach  the  point  of  infection ;  but 
with  the  addition  of  the  artificially  induced  hyperemia,  we 
were  able  to  bring  the  immune  elements  to  the*  point  of  the 
local  infection. 

Since  we  are  dealing  here  with  the  natural  forces  that 
are  instrumental  in  overcoming  infection,  and  the  assistance 


156  TUBERCULIN  AND  VACCINE 

we  give  consists  in  intensifying  these  processes,  the  usual 

The  necessary,  surgical  measures  that  are  deemed  necessary  can  be  more  or 

l^rgica1*"  less  modified,  not  only  as  to  the  time  of  operations  as  sug- 

measuresmay  gested  above,  but  also  to  the  extent  of  these  surgical  meas- 

modified  in  the  ures.     Thus,  if  the  increased  supply  of  antibodies  will  over- 

fn'reasing1  come  the  bacterial  invasion,   it  stands  to  reason  that  the 

immunity  evacuation  of  the  pus  already  present  is  quite  sufficient  with- 

acquired  dur-  •,-,.•,  /•  T-<  i 

ing  tuberculin      out  the  establishment  of  drainage,     -bor  the  same  reason, 

treatment™         w^e  incisions  may  be  dispensed  with,  and  either  aspiration 

or  puncture  may  suffice.    At  any  rate,  the  increased  immune 

response  will  eliminate  the  danger  of  the  spread  of  'the  in- 

fection even  though  it  may  not  be  quite  enough  to  prevent 

the  local  formation  of  inflammatory  products.     In  this  case, 

the  puncture  will  be  sufficient  to  prevent  such  discharges 

from  being  retained  ;  and  the  trouble  of  re-aspiration  will 

be  more  than  repaid  by  the  final  cosmetic  effect. 

The  cold  In  this  connection,  it  is  also  well  to  remember  that  the 


point  ing  of  cold  abscesses  may  not  be  due  to  mixed  infection 


at  all,  but  to  a  digested  ferment  which  is  excreted  by  the 
than  has  been  cells  lining  the  abscess.  These  ferments  digest  the  tissues  of 
>rded  to  it.  tne  wa]j^  eniarging  tne  abscess  in  all  directions,  giving  it  the 
appearance  of  pointing  when  the  process  approaches  the  sur- 
face. Puncture  or  aspiration  is  absolutely  essential  under 
these  circumstances  before  the  process  has  come  too  near  the 
surface;  for  unlike  an  infection,  there  is  no  inflammatory 
hyperemia  surrounding  the  area  where  the  abscess  breaks 
through.  Hence,  the  unresisting  surface  forms  more  or  less 
a  sloughing  process,  causing  a  very  ugly  broken-down  surface 
with  ultimate  extensive  scarring. 


CHAPTER  II 


The   subject   of  mixed   infection   is   recently   receiving  TOO  little 

attention 
given  to 


more  attention  than  it  has  been  getting  for  some  time.    How- 


ever, it  still  falls  far  short  of  the  attention  that  it  deserves.   c°-existing 

infections 

One  cannot  work  in  tubercular  conditions  very  long  without  in  tubercular 
becoming  convinced  that  many  a  patient  would  have  suc- 
ceeded in  overcoming  the  tubercular  infection  were  it  not 
for  a  mixed  infection  that  kept  the  flame  smoldering. 

One  need  not  be  surprised  in  coming  here  and  there  upon  The  removal 

a  case  where  a  vaccine  for  a  mixed  infection  will  clear  the  "nfe'ction^m 

whole  trouble.     The  balance  between  the  infection  with  the  clearly  define 

tubercle  bacillus   and  the  mixed  infection  with  the  other  the  tubercular 

bacteria  is  sometimes  so  fine  that  it  is  difficult  to  determine  process>  a"d 

thus  simplify 

which  is  producing  the  symptoms.     This  is  particularly  true  the  tuberculin 

,.  .  Trr  -i  ,.     .     treatment. 

in  patients  running  a  temperature,  we  can  avoid  wasting 
a  great  deal  of  time  during  the  tuberculin  treatment  when  a 
temperature  is  caused  by  mixed  infection ;  for  if  we  consider 
that  temperature  of  tubercular  origin,  the  amount  of  tuber- 
culin we  are  advised  to  give  (Will  be  far  less  than  for  a  simi- 
lar condition  without  temperature.  Xow,  if  we  can  clear 
the  temperature  by  means  of  a  mixed  infection  vaccine, 
the  tuberculin  treatment  in  such  cases  will  then  be  more 
definite  and  accompanied  by  less  hesitancy  as  to  its  con- 
tinuation. 

Perhaps  a  great  deal  of  hesitation  in  the  use  of  vaccines   The  empirical 
in  mixed  infections  is  due  to  the  indefinite  results  often  ob-  of  va'ccines 
tained  with  them.     These  faulty  results  are  another  illus-  has  hindered 

"  .  their  wider  use. 

tration  of  the  ineffectiveness  of  the  stereotyped  use  of  a 
therapeutic  agent  that  depends  upon  the  stimulation,  of 
natural  processes  which  are  so  complicated  and  so  different 
in  different  individuals.  We  cannot  administer  vaccines  any 
more  than  tuberculins  in  formulated  recipes,  as  we  admin- 


158  TUBERCULIN  AND  VACCINE 

ister  drugs.  Nor  can  we  use  vaccines  .without  absolute 
definite  reference  to  the  causative  bacteria,  to  the  virulence 
of  the  infection,  and  to  tie  individual  resistance. 

Diagnosis  of  Infective  Organism 

A  correct  ^  momentary  contemplation  of  the  heading  of  this  topic 

diagnosis  of 

the  causative  will  impress  the  reader  at  once  with  the  importance  of  this 
CM™"™  'S  subject.  Nevertheless,  very  little  has  been  said  on  this  sub- 
before  a  proper  ject  jn  the  past,  and  still  less  has  been  done.  It  is  therefore 
Obtained  for  clear  that  the  element  which  would  have  rendered  the  whole 
subject  of  vaccine  therapy  much  simpler  and  infinitely  more 
infection.  scientific  has  been  entirely  overlooked,  namely, — the  bac- 

teriological diagnosis  of  the -infection.  Some  have  depended 
upon  the  laboratories  to  make  their  vaccines  and  to  give  the 
directions  for  their  use;  while  others  have  used  mixed  vac- 
cines which  were  supposed  to  be  applicable  for  all  forms  of 
infection.  Again,  proprietary  mixtures  were  employed  with 
2  list  of  diseases  [for  which  they  should  be  used,  and  with 
directions  for  dosage.  As  neither  the  laboratory  nor  the 
proprietary  manufacturers  can  have  any  idea  of  the  condi- 
tion in  question,  the  physician  administering  the  vaccines  not 
only  fails  to  understand  the  composition  of  the  vaccines,  but 
is  just  as  hazy  with  regard  to  the  infection  with  which  he  is 
dealing. 

All  this  forms  a  condition  in  the  sphere  of  immotherapy 
that  may  lead  not  only  to  bad  results  but  even  to  a  premature 
death  of  the  entire  subject.  Such  a  state  of  affairs  would 
bring  about  no  less  a  calamity  than  the  loss  of  the  value  of 
tuberculin  in  tubercular  conditions. 

How  different  would  the  aspect  of  vaccine  therapy  be 
if  due  consideration  would  be  given  to  the  diagnosis  of  the 
infection?  Once  the  diagnosis  of  the  infectious  organism 
is  established,  we  could  then  demand  from  the  laboratory  a 
vaccine  made  from  the  infectious  organism  no  matter  what 
other  bacteria  happened  to  contaminate  our  culture  media 
or  our  infected  material. 


INFECTIOX  159 

Or  if  the  stock  vaccine  be  used,  we  could  simply  pur- 
chase a  vaccine  for  this  particular  infectious  organism.  We 
could  then  treat  the  patient  with  the  specific  vaccine,  and 
abandon  the  use  x>f  a  mixture  of  organisms  which  we  have 
been  using  with  the  hope  that  one  of  them  may  reach  the 
mark  the  rest  having  no  bearing  on  the  infection.  Having 
made  the  diagnosis,  the  appropriate  vaccine  will  be  an  agent 
of  precision  in  the  hands  of  the  physician,  and  will  do  away 
with  probing  in  the  dark  which  is  brought  about  by  an  in- 
sufficient knowledge  of  what  is  being  accomplished  during 
treatment.  . 

It  will  be  possible  to  gauge  the  treatment  by  the  condition 
at  hand,  and  acquire  that  exactness  which  alone  will  make 
possible  the  clear  insight  into  the  mechanism  of  immuno- 
therapy. 

To  arrive  at  an  exact  diagnosis  of  the  infection,  we  have 
the  following  methods  at  our  command:  the  smear  for  micro- 
scopic examinations ;  cultures  on  appropriate  culture  media ; 
physical  diagnosis;  and  animal  inoculation. 

Smear  Diagnosis.  It  is  not  necessary  to  have  a  special  A  simple  smear 
biological  training  in  order  to  be  able  to  utilize  this  form  of  ^ethyie^'biue, 
diagnosis.  The  variety  of  bacteria  that  we  deal  with  in  the  wil1  disclose 

.     f        .    *  -,  .,,.  .,.,..  under  the 

more  common  infections  and  especially  in  mixed  infections  microscope 
in  tubercular  patients  are  few  in  number  and  easily  dis-  thecausatlve 

"  organism  in 

tinguishable.     A  few  hours  of  reading  in  any  of  the  simpler  the  large 
text-books  on  the  subject  will  be  sufficient  to  give  all  the  instances, 
data    that   are   necessary   for    a    working   basis    in   vaccine 
therapy. 

In  the  majority  of  cases,  the  simple  methylene  blue  stain 
will  suffice.  In  others,  a  differential  stain  for  the  tubercle 
bacillus  and  perhaps  Gram's  stain  may  be  used.  All  in  all, 
the  making  of  a  smear  diagnosis  of  mixed  infection  consists 
in  making  on  a  slide  a  smear  of  the  pus  discharged  from  a 
fistula,  or  sputum ;  fixing  it  in  the  flame ;  then  covering  it 
with  an  aqueous  solution  of  methylene  blue  for  a  minute 
or  two ;  rinsing  the  slide ;  then  when  dry  placing  a  drop  of 


160  TUBERCULIN  AND  VACCINE 

cedar  oil  on  it;  and  finally  examining  it  with  the  oil  im- 
mersion lens. 

The  staphylococcus,  jthe  streptococcus,  the  colon  bacillus 
and  the  pneumococcus  are  so  easily  distinguishable  that  one 
does  not  require  a  second  glance  in  the  microscope  to  recog- 
nize the  offender.  Of  course,  frequently  secretions  contain 
so  few  of  the  offending  organisms  that  we  must  depend  upon 
a  cultural  growth  for  diagnosis.  (This  subject  will  be  dis- 
cussed under  the  heading  of  "  Cultures.") 

But  a  short  practice  with  smear  diagnosis  is  required  to 
make  it  evident  that  very  frequently  the  offending  organism 
fails  to  grow  in  the  culture  tube  even  though  it  is  evident 
in  the  smear.  It  is  a  known  fact  that  the  more  virulent  a 
bacteria,  the  greater  the  difficulty  in  obtaining  a  growth  on 
an  artificial  medium ;  and  that  the  avirulent  strains  not  only 
grow  more  readily  on  the  artificial  medium  but  will  inhibit 
the  growth  of  the  virulent  bacteria  which  are  necessary  for 
the  production  of  the  vaccine.  Thus  it  may  happen,  that 
the  smear  shows  a  streptococcus,  while  the  growth  in  the 
culture  tube  reveals  a  staphylococcus,  the  latter  having  either 
gotten  in  through  a  surface  infection,  or  from  the  pus  where 
it  took  no  part,  in  the  actual  infection.  This  staphylococcus 
being  avirulent,  crowded  out  the  streptococcus  by  its  rapid 
growth.  So  long,  however,  as  a  smear  revealed  the  strepto- 
coccus as  the  causative  organism,  a  second  or  even  a  third 
culture  will  finally  yield  the  proper  growth  for  a  vaccine. 
If  a  culture  is  sent  to  a  laboratory,  the  request  must  accom- 
pany the  culture  to  make  the  vaccine  of  the  organism  found 
to  be  the  one  causing  the  infection.  The  laboratory  will  find 
no  difficulty  in  isolating  the  causative  organism  through  sub- 
cultures, and  if  it  fails  to  grow,  the  laboratory  will  so  report 
to  the  physician  and  avoid  making  a  vaccine  of  the  wrong 
bacteria.  This  can  be  accomplished  only  by  a  correct  diag- 
nosis of  the  causative  organism  in  the  first  place.  A  large 
number  of  failures  in  vaccine  therapy  will  thus  be  elimi- 
nated. Moreover,  the  practice  of  smear  diagnosis  brings  us 


"'* 


..../* 


t./ 

^>'..«* 


MIXED  INFECTION  161 

face  to  face  with  ,the  enemy  we  are  fighting,  consequently 
simplifying  the  whole  subject;  and  since  simplicity  leads 
to  precision,  the  labor  involved  carries  with  it  a  commen- 
surate compensation. 

Cultures.    One  of  the  important  points  of  consideration   The  appearan 
in  the  steps  between  the  infection  as  it  presents  itself  to  us 


and  the  vaccine  is  the  inoculated  culture  tube.     The  proper  aidinth« 

diagnosis  of 

media  are  easily  obtained  and  all  that  is  necessary  in  order  the  causative 
to  get.  the  proper  vaccine  is  ,a  growth  of  the  bacteria  that  is 
causing  the  infection.  The  culture  tubes  are  put  up  in  con- 
venient form  for  inoculation  and  transportation.  However, 
if  we  are  to  utilize  (the  appearance  of  cultural  growth  for 
diagnosis,  we  have  to  grow  the  bacteria  in  our  office,  and  at 
the  proper  incubation  temperature. 

Here  again,  a  serious  barrier  to  yaccine  therapy  seems 
to  arise  in  the  shape  of  costly  and  Complicated  apparatus. 
If  we  remember,  however,  that  the  essential  for  the  growth 
of  the  bacteria  is  a  temperature  of  97°  to  99°  F.,  the  means 
by  which  we  can  maintain  such  temperatures  is  of  no  conse- 
quence. Hence,  it  sometimes  suffices  to  carry  the  culture 
tube  in  the  inside  vest  pocket,  if  a  culture  is  taken  in  the 
morning,  in  order  to  obtain  a  sufficient  growth  for  diagnosis 
by  the  evening.  Another  convenient  means  of  incubation  is 
a  thermos  bottle.  This  may  [be  (filled  with  water  at  a  tem- 
perature of  101°  or  102°  F.  The  infected  culture  tube 
when  placed  in  water,  will  reduce  the  heat  to  about  98°  F. 
Care  must  jbe  taken  to  prevent  the  water  from  entering  upon 
the  culture  media. 

The  cultural  growth  of  these  bacteria  is  required  not 
only  for  the  diagnosis  of  the  invading  organism,'  such  as 
the  differentiation  between  the  albus,  aureus  and  the  citreus 
forms  of  the  staphylococcus  ;  but  it  is  also  necessary  where 
the  laboratory  for  the  making  of  the  autogenous  vaccine  is 
at  a  distance,  requiring  the  transportation  of  the  culture 
tube  under  adverse  temperature  conditions.  Under  these 
circumstances,  the  growing  of  these  bacteria  before  trans- 
11 


TUBERCULIN  AND  VACCINE 


The  diagnosis 
of  the 
causative 
organism 
by  means 
of  animal 
inoculation 
is  so  seldom 
necessary 
that  it 
requires  no 
consideration 
here. 


The  physical 
appearance 
of  the  pus 
and  of  the 
infected 
area  may 
sometimes 
aid  in  the 
diagnosis  of 
the  causative 
organism. 


portation  or  exposure  will  make  it  possible  for  these  bacteria 
to  reach  the  laboratory  alive.  Wte  know  the  difficulty  in 
growing  the  streptococcus;  how  quickly  it  dies  under  the 
best  conditions  in  the  culture  media.  An  incubation  at 
proper  temperature  for  about  twelve  hours  will  so  increase 
the  number  of  these  bacteria  that  a  sufficient  number  of 
them  will  reach  the  laboratory  for  sub-culture  and  for  the 
manufacture  of  the  vaccine.  Here  again,  as  in  the  case  of  the 
smear  diagnosis,  an  intimate  knowledge  of  the  physical  ap- 
pearance and  of  the  characteristics  of  these  few  important 
organisms  is  essential — a  knowledge  that  will  not  only  bring 
about  a  gratifying  understanding  of  the  subject,  but  will 
help  materially  in  the  success  of  immunotherapy. 

Animal  Inoculation.  Fortunately  bacterial  diagnosis 
does  not  frequently  call  for  animal  inoculation.  When  it 
does,  it  applies  only  to  the  tubercle  bacillus.  'Many  cases 
where  animal  inoculations  may  be  thought  necessary  can  be 
cleared  up  by  resorting  to  tuberculin  tests  as  described  under 
their  respective  headings  in  the  chapter  on  "  Tests."  . 

Thus  the  field  of  animal  inoculation  is  exceedingly  lim- 
ited. In  those  exceptional  cases  where  this  method  remains 
the  only  source  of  diagnosis  we  must  resort  to  it  only  if  we  are 
not  within  reach  of  a  well-equipped  laboratory.  Otherwise, 
it  may  be  found  simpler  in  such  instances  to  give  a  course 
of  tuberculin  even  if  it  entails  the  eventuality  of  treating 
a  non-tubercular  case  with  tuberculin.  ~No  harm  can  be 
done  with  tuberculin  in  a  non-tubercular  case,  whereas  a 
great  deal  of  good  will  be  accomplished  if  the  case  is  tuber- 
cular in  nature. 

Physical  Signs.  Occasionally  we  have  to  deal  with  an 
urgent  form  of  mixed  infection  where  it  is  necessary  to 
use  a  stock  vaccine  immediately  and  where  the  infection  is 
beyond  reach,  making  a  smear  or  culture  impossible.  In  such 
cases  we  may  sometimes  get  a  fairly  good  clue  to  the  nature 
of  the  invading  organism  by  means  of  physical  signs.  Thus, 
the  temperature  curve  may  point  to  a  streptococcus  infection. 


MIXED  IXFECTIOX  163 

An  erysipelas  can  be  diagnosed  from  outward  appearance 
and  a  stock  erysipelas  vaccine  used.  A  septic  condition  with 
a  sero  discharge  may  point  to  a  streptococcus  infection ;  and 
a  creamy  discharge,  to  a  staphylococcus.  The  odor  of  a  dis- 
charge may  point  to  the  colon  bacillus.  The  location  may 
occasionally  be  a  clue,  as  for  instance,  a  mixed  infection  in 
kidney  tuberculosis  would  point  to  a  colon  infection. 

The  following  history  illustrates  the  importance  of  the 
correct  diagnosis  of  the  causative  organism. 

The  patient,  a  woman  twenty-eight  years  of  age,  was  operated  on 
by  suprapubic  cystotomy  for  severe  hemorrhage  into  the  bladder  from 
tuberculous  ulcerations  in  the  bladder  wall.  Three  or  four  days  later 
she  had  a  severe  chill,  followed  by  temperature  rise  to  104°  or  105°, 
and  for  ninety-three  days  this  daily  temperature  rise  continued,  with 
remissions  to  below  normal.  Her  condition  at  this  time  became  very 
grave.  She  was  greatly  emaciated.  About  the  ninetieth  day,  tubercle 
bacilli  were  found  in  her  urine  and  for  the  first  time  the  tuberculous 
origin  of  the  trouble  was  discovered.  This  discovery  was  responsible 
for  my  being  called  in  on  the  case  by  the  attending  physician,  who 
knew  my  work  with  tuberculin.  The  question  of  vaccine  had  not  been 
considered  up  to  this  time.  As  previously  stated,  acute  infection  had 
now  lasted  for  ninety-three  days,  and  on  examination  I  found  her  suf- 
fering from  what  appeared  to  me  to  be  a  streptococcus  septicemia.  All 
urine  came  from  the  suprapubic  incision,  but  was  not  recognizable  as 
urine;  it  was  a  thick,  creamy  discharge  having  a  microscopic  appear- 
ance of  pure  pus  and  which  on  analysis  showed  urinary  elements.  A 
microscopical  examination  showed  numerous  tubercle  bacilli,  a  short- 
chain  small  streptococcus,  a  staphylococcus,  and  a  small  micrococcus,  the 
identification  of  which  we  did  not  deem  worth  while  at  the  time. 
Suitable  culture  media  were  at  once  inoculated  and  a  vaccine  of  the 
streptococcus  was  ordered.  Meantime  a  stock  streptococcus  from  a 
similar  condition  was  at  once  administered  in  order  not  to  lose  time  in 
waiting  for  the  autogenous  vaccine.  Eepeated  laboratory  reports,  after 
cultures  on  various  media,  stated  that  no  streptococcus  grew  in  the 
media,  and  not  until  almost  a  week  had  elapsed  did  .the  streptococcus 
finally  grow.  Until  then  the  growth  always  showed  a  small  micrococcus 
unidentified,  a  staphylococcus,  or  the  colon  bacillus;  but  these  were 
rejected  as  I  was  convinced  from  the  pus  appearance  in  the  smear,  and 
from  the  course  of  the  infection  that  the  streptococcus  was  the  causative 
organism.  The  stock  vaccine  proved  efficient ;  not  only  had  the  patient  'a 
temperature  dropped  to  normal  within  forty-eight  hours  after  the  first 
inoculation,  but  after  three  more  inoculations,  during  a  period  of  two 
weeks,  she  was  out  of  bed.  Pure  urine  appeared  from  the  suprapubic 
wound  with  only  a  microscopic  trace  of  pus.  Tuberculin  treatment  was 
instituted  ten  days  after  the  first  inoculation  of  vaccine.  During  the 
following  four  months  of  treatment,  the  suprapubic  wound  closed  com- 
pletely; the  urine  became  free  from  tubercle  bacilli;  and  the  patient's 
weight  which  had  been  ninety  pounds  increased  to  one  hundred  and 
sixteen  pounds. 

Incidentally  this  case  demonstrates  the  successful  treatment  of  renal 
tuberculosis  with  tuberculin.  It  is  now  a  year  since  the  conclusion  of 
treatment,  and  none  of  the  symptoms  referable  to  renal  tuberculosis  or 
bladder  ulcerations  have  reappeared. 


CHAPTER  III. 
VACCINES 

Definition.  it  does  not  come  within  the  scope  of  this  work  to  give  a 

detailed  account  of  the  methods  of  preparing  vaccines.  I 
shall  enter  into  it  more  in  detail  in  a  forthcoming  work 
dealing  with  vaccines  exclusively.  However,  I  might  men- 
tion that  a  vaccine  is  a  watery  suspension  of  dead  bacteria, 
the  bacteria  killed  in  such  a  way  as  to  produce  the  least 
morphological  or  chemical  change  in  the  bacteria.  Such 
alteration  must  be  avoided  in  order  that  the  bacteria  retain 
Their  power  of  stimulating  the  specific  antibody  when 
inoculated. 

Preparation 

It  is  necessary  to  make  sub-cultures  from  the  original 
inoculated  media,  in  order  to  make  sure  that  we  have  a 
pure  culture  of  the  specific  bacteria.    A  sufficient  growth  on 
the  sub-culture  must  be  obtained  in  order  to  get  a  sufficient 
in  the  quantity  of  vaccine  for  the  entire  treatment.     'For  after 

vaccine  treatment  has  been  instituted,  it  may  become  im- 

of  vaccines  •' 

a  sufficient  possible  to  obtain  growths  from  the  discharges  even  though 
complete  the  complete  immunity  has' not  yet  been  established.  This  would 
treatment  necessitate  waiting  for  a  recurrence  of  the  infection  in  order 

should  be 

made.  to  be  able  to  obtain  more  vaccine, — thus  causing  unneces- 

sary delay  and  vitiating  to  a  large  extent  the  former  vaccine 
treatment. 

Standardization.     The  standardization  of  vaccines  must 

be  made  as  nearly  accurate  as  possible.    I  have  seen  a  great 

deal   of  harm  done  by  faulty  methods  of  standardization. 

Proper  The  following  example  may  serve  to  bring  out  the  necessity 

standardization  *.  "  * 

is  essential.         for  proper  standardization  more  effectively  than  any  dis- 
course I  can  give  on  the  subject. 

A  comminuted  fracture  of  the  elbow  joint  became  in- 
fected, and  showed  the  staphylococcus  albus  in  pure  culture 


VACCIXES  165 

as  the  causative  organism.  A  vaccine  was  made,  and  stand- 
ardized  by  a  method  of  comparison  of  the  viscosity  of  the 
vaccine  with  test  tubes  filled  with  known  strengths  of  vac- 
cines. The  first  dose  administered  produced  a  violent  nega- 
tive phase.  The  violent  rise  of  temperature  and  tremendous 
increase  of  the  local  inflammation  was  not  attributed  to  the 
vaccine,  but  to  the  extension  of  the  infection.  I  was  sum- 
moned in  consultation ;  and  from  the  appearance  of  the  tem- 
perature curve,  I  was  convinced  that  it  was  due  to  a  nega- 
tive phase.  The  undue  turbidity  of  the  vaccine  led  me  to 
bring  it  to  our  laboratory  for  re-standardization.  The  bac- 
terial count  disclosed  the  vaccine  to  be  nearly  one  and  one- 
half  times  as  strong  as  the  label  read.  The  infection  cleared 
up  after  two  injections  of  the  vaccine,  doses  being  used 
according  to  the  new  standardization.  The  effect  was  so 
marked  that  it  left  no  room  for  doubt  that  it  was  brought 
about  by  the  proper  use  of  the  vaccine. 

The  best  methods  of  standardization  of  bacterial  sus- 
pensions in  use  at  the  present  time  are: 

1.  Wright's    Method,    which    requires    the    mixing    of 
equal  parts  of  freshly  drawn  blood  from  a  healthy  indi- 
vidual   (usually  from  the  worker's  own  finger),   and  bac- 
terial suspension  diluted  and  stained,  and  placed  in  a  count- 
ing chamber,  in  the  same  manner  as  for  red  blood  count. 
The  number  of  bacteria  and  the  number  of  red  blood  cor- 
puscles are  counted  in  a  number  of  squares,  and  an  average 
is  obtained  for  each.     By  figuring  the  proportion  between 
the  bacteria  and  the  red  blood  corpuscles  to  the  known  five 
million  red  blood  corpuscles  per  cubic  millimeter,  the  num- 
ber of  bacteria  per  cubic  millimeter  will  be  obtained.     This 
number  multiplied  by  ten  will  equal  the  number  of  bacteria 
per  cubic  centimeter. 

2.  By  a  direct  count  of  the  number  of  bacteria,  in  the 
same  manner  and  by  means  of  the  same  apparatus  as  a  blood 
count  for  the  number  of  red  corpuscles  is  made. 

For  more  specific  directions,  see  any  laboratory  guide. 


160 


TUBERCULIN  AND  VACCINE 


Improper 

containers 

will  frequently 

produce 

negative 

results  from 

vaccine 

treatment 

of  mixed 

infection. 


Example. 


Containers.  At  first  glance,  it  may  seem  trivial  to  even 
mention  the  subject  of  containers  for  vaccines.  But  the 
success  of  vaccine  therapy  may  sometimes  depend  on  a 
minute  detail. 

For  one  thing,  the  former  method  of  dispensing  vaccines 
in  ampules  should  be  discarded.  The  sealing  of  the  ampules 
necessitates  the  drawing  out  of  the  heated  glass  to  a  very 
thin  neck.  If,  perchance,  the  box  containing  the  ampules 
is  allowed'  to  stand  for  a  day  or  two  in  such  a  position  that 
the  ampules  are  upside  down  within  the  box,  the  bacteria 
will  precipitate  into  the  very  thin  neck.  "When  the  vaccines 
are  administered,  these  thin  necks  are  filed  or  broken  off 
and  thrown  away  with  the  active  principles  of  the  vaccines. 
Even  though  we  recognize  the  precipitated  bacteria  in  the 
neck,  and  attempt  to  shake  it  out  into  the  body  of  the 
ampule,  we  may  in  many  instances  only  half  succeed  and  so 
make  our  administered  dose  quite  different  from  our  in- 
tended one.  • 

The  following  case  will  not  only  illustrate  the  necessity 
for  good  containers,  but  will  emphasize  the  fact  that  atten- 
tion to  details  is  absolutely  necessary  when  dealing  with 
immunotherapy : 

A  girl,  twelve  years  old,  was  sent  to  me  for  advice  as  to 
the  use  of  vaccine  for  a  colon  pyelitis.  One  year  previously 
she  had  a  kidney  removed  for  the  relief  of  a  severe  pyelo- 
nephritis. Since  this  was  an  infection  of  her  only  kidney, 
surgical  intervention  was  out  of  the  question  this  time, — 
this  fact  forming  the  main  reason  for  referring  the  case 
to  me.  I  advised  the  use  of  vaccine,  and  gave  full  directions 
as  to  dosage,  etc. 

Three  months  later  the  little  patient  was  brought  to  me  by 
the  mother,  upon  the  advice  of  the  physician  in  charge,  with 
the  statement  that  the  vaccines  had  produced  no  result  what- 
ever. The  temperature  records  showed  that  the  daily  rise 
between  101°  and  102°  F.  previous  to  the  vaccine  treatment, 
had  in  no  way  changed  during  the  treatment.  Urine  exami- 


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VACCINES  167 

nation  showed  just  as  much  pus  and  bacteria  as  ever.  Since 
vaccine  therapy  in  this  case  was  considered  a  method  of 
last  resort,  the  child  was  now  again  referred  to  me  with  the 
hope  that  personally  I  might  be  more  successful  than  through 
the  physician  in  charge. 

The  patient's  mother  brought  with  her  the  autogenous 
vaccine  which  consisted  of  a  box  of  ampules,  each  ampule 
containing  one  cubic  centimeter  of  the  vaccine.  This  vac- 
cine was  made  at  the  Polyclinic  laboratory  and  there  was 
no  question  as  to  its  proper  standardization.  I  took  one 
ampule  and  noticed  the  precipitate  in  the  neck.  I  began 
to  shake  it  very  vigorously,  and  continued  to  shake  it  for 
some  time  until  all  visible  precipitate  was  out,  and  the  clear 
fluid  in  the  body  of  the  ampule  became  viscid.  I  then  broke 
the.  neck  off  and  drew  the  appropriate  amount  into  the 
syringe  ready  for  inoculation.  My  vigorous  efforts  at  shak- 
ing the  ampule  attracted  the  attention  of  the  little  girl,  who 

thereupon  exclaimed  to  the  mother,  "  Doctor never 

did  that.  Has  something  happened  to  the  vaccine  on  the 
way  over  ?  "  The  reason  for  the  failure  of  at  least  eighteen 
inoculations  of  vaccine  given  previous  to  this  consultation 
at  once  became  evident.  The  child  had  been  inoculated  with 
normal  saline  plus  one-half  per  cent,  phenol,  but  with  no 
vaccine.  That  went  into  the  waste  with  the  discarded  neck 
of  the  ampule. 

After  two  inoculations  at  my  office  the  temperature  was 
normal  and  after  four  more  all  traces  of  pus  disappeared 
from  the  urine.  The  child  gained  rapidly  in  weight,  increas- 
ing in  the  next  thirteen  months  at  least  forty  per  cent,  over 
her  former  weight. 

The  best  container  consists  of  a  bottle  holding  between 
five  and  twenty  cubic  centimeters,  covered  with  a  good  qual- 
ity rubber  cap  through  which  the  needle  may  be  plunged 
and  the  appropriate  amount  aspirated.  (Figs.  43  and  44.) 
Little  bottles  containing  one  cubic  centimeter  each  and 
corked  with  a  minute  rubber  cork,  will  frequently  modify 


168  TUBERCULIN  AND  VACCINE 

Proper  care         ^  actjve  principle  of  the  vaccine.     I  have  seen  the  pre- 

of  vaccines.  * 

cipitated  bacteria  cling  to  the  cork  when  pulled  out,  even 
after  vigorous  shaking,  if  the  box  containing  the  bottle  had 
been  placed  upside  down  for  a  length  of  time. 

Care  of  Vaccines.  Vaccines  should  be  kept  in  a  dark 
place.  They  should  be  kept  in  a  cool  temperature, — prefer- 
ably in  an  icebox.  They  are  never  to  be  used  when  the  color 
changes  and  the  liquid  begins  to  assume  a  brownish  hue. 

Stock  Vaccines 

A  stock  vaccine  is  a  vaccine  that  is  derived  from  an 
An  autogenous  organism  not  taken  from  the  lesion  to  be  treated.  The 
vaccine  general  notion  of  a  stock  vaccine  is  that  it  is  manufac- 

becomes  a 

stock  vaccine  tured  and  put  up  for  commercial  sale  by  some  concern  deal- 
Tsi^uar  ing  in  biological  products.  This  conception  entirely  over- 

infection  in         looks  the  fact  that  any  autogenous  vaccine  is  a  stock  vaccine 

a  different  .        .    7 

individual.          when  used  on  another  individual  suffering  from  an  infection 
caused  by  the  same  bacteria. 

Such  a  stock  vaccine  coming  as  it  does  from  an  infection 

which  we  have  handled,  can  be  labeled  with  a  short  description 

of  the  case  it  was  derived  from.     These  descriptions  can  serve 

to  subdivide  our  vaccines  of  the  sanie  organism  into  various 

In  the  forms  of  infections  caused  by  the  same  organism.     Thus  we 

manufacture        are  a^je  not  on]v  fo  have  stock  vaccines  of  certain  bacteria, 

of  a  stock  •* 

vaccine,  the  but  even  in  a.  general  way  to  obtain  stock  vaccines  of  differ- 
^"obtain^d  ent  strains  of  the  same  bacteria.  In  that  way,  we  can  utilize 
resembles  the  our  ]ef  t-over  autogenous  vaccines  as  excellent  stock  vaccines 

strain  of  the  . 

causative  for  similar  conditions.    Whether  gtock  vaccines  are  the  left- 

oft^e'r  k'wm      over  autogenous  vaccines  from  other  patients,  or  those  sold 
prove  effective,     on  the  market   by  proprietary  concerns,   there  can  be  no 
doubt  about  their  therapeutic  value. 

It  is  difficult  to  compare  with  accuracy  the  relative  value 
of  stock  and  autogenous  vaccines.  But  a  stock  vaccine  is 
effective  in  a  sufficiently  large  percentage  of  cases  to  justify 
its  use  before  an  autogenous  one  is  made. 

However,  there  is  one  element  in  the  consideration  of 


VACCINES  169 

stock  vaccines  which  has  done  much  to  discredit  their  use,  The  use  of 
and  which  we  must  eliminate  before  stock  vaccines  will  merit  has  done'mw-h 
recommendation.     I  am  referring  to  the  poly-vaccines  put  ^wincrf 
up  for  the  market.     The  practice  of  poly-pharmacy,  except  va<=c'nes '" 
in  ia  very  moderate  degree  is  at  all  -times  to  be  condemned. 
But  to  apply  the  same  principle  in  the  matter  of  vaccines  is 
indefensible.     If  we  deal  with  an  infection  which  is  caused 
by  more  than  one  organism,  a  separate  vaccine  should  be 
made  of  each,  and  administered  in  such  proportions  as  the 
exigencies  of  the  case  may  require. 

Immunotherapy  depends  for  its  success  upon  a  fair  judg- 
ment of  the  immune  response ;  and  how  are  we  ever  to  learn 
to  estimate  the  effect  of  vaccine  therapy,  if  we  are  to  use  a 
multitude  of  different  bacteria  with  the  hope  that  one  of 
them  will  produce  the  desired  effect.  I  have  gone  into 
great  detail  on  the  subject  of  bacterial  diagnosis  because  of 
the  importance  of  knowing  the  enemy  with  whom  we  are 
dealing.  For  a  thorough  understanding  of  our  enemy  is  the 
first  esential  in  effecting  his  conquest. 

Why,  then,  grope  in  the  dark  with  the  use  of  vaccines? 
If,  for  instance,  we  are  dealing  with  a  staphylococcus  infec- 
tion, why  use  a  colon  or  a  streptococcus  with  it?  Again, 
supposing  that  we  have  with  a  staphylococcus  a  colon  infec- 
tion ;  by  the  use  of  a  poly-vaccine  consisting  of  staphylococ- 
cus and  colon  mixed,  the  colon  responds  so  much  more  easily 
to  vaccine  treatment,  that  a  radical  increase  in  its  dose  would 
be  not  only  useless,  but  even  harmful ;  and  still,  such  radical 
increase  will  have  to  be  made  along  with  the  necessary 
increase  in  the  staphylococcus. 

I  heartily  recommend  stock  vaccine;  and  the  polyvalent   Polyvalent 
product  as  put  out  by  the  better  known  manufacturers  is  are  to  be 
excellent.     But  these  vaccines  should  be  sold  onlv  in  separ-  «c°mmend«d 

only  when  put 

ate  containers  of  sufficiently  high  concentration  to  make  it  up  in  separate 

i     -11         •  i     ,  •  i  •     •  containers. 

unnecessary  to.  give  a  bulky  inoculation  when  mixing  two 
or  more  bacteria  in  case  of  multiple  infection. 

It  is  for  the  physician  to  judge  when  to  mix  the  vaccines 


170 


TUBERCULIN  AND  VACCINE 


The  mixing 
of  the  various 
bacterial 
vaccines  in 
the  treatment 
of  a  multiple 
infection 
should  be 
done  by  the 
physician 
alone,  as  he  is 
the  only  judge 
of  the  dosage 
required. 


The  advantages 
of  autogenous 
vaccine  over 
stock  vaccine: 
are: 

1  It  is  always 
of  the  same 
strain  of 
bacteria  as 
the  infection. 

2  It  is  always 
fresh. 


and  the  quantity  that  should  be  used  of  each.  Happily,  the 
proprietary  concerns  are  now  putting  out  vaccines  of  individ- 
ual bacteria  and  of  high  concentration ;  so  that  the  physician 
can  have  a  container  full  of  from  ten  to  twenty  cubic  centi- 
meters of  each  bacteria  on  hand.  And  'after  a  careful  diag- 
nosis of  the  causative  organism  or  organisms,  he  can  draw 
into  his  syringe  the  proper  quantity  from  each  container  as 
the  case  may  require,  and  inoculate  his  patient  with  the 
mixture.  In  that  way  he  will  know  what  he  is  using.  Sub- 
sequent smears,  cultures  or  laboratory  examinations  will 
guide  him  as  to  the  continuation  or  the  elimination  of  any 
one  of  the  bacteria  that  he  has  been  using  in  the  treatment 
of  the  infection.  At  the  same  time,  he  will  not  be  treating 
the  patient  with  a  vaccine  of  all  the  bacteria  at  once,  but  will 
have  the  choice  of  administering  a  vaccine  of  one  bacteria 
after  another,  a  practice  which  will  be  found  especially  valu- 
able and  illuminating  in  mixed  infections  in  tubercular  sub- 
jects. The  treatment  of  a  tubercular  condition  offers  a  suf- 
ficient length  of  time  for  such  practice. 

Xot  only  will  the  serial  use  often  remove  the  necessity 
of  using  a  vaccine  for  other  bacteria  besides  the  principal 
one  he  has  chosen  to  begin  with  (the  discovery  will  often  be 
made,  that  the  other  bacteria  merely  kept  company  in  a 
fungoid  form),  but  it  will  also  afford  an  opportunity  for  an 
experience  in  vaccine  therapy  that  will  more  than  repay  for 
the  trouble. 

Autogenous  Vaccines 

An  autogenous  vaccine  is  a  vaccine  made  of  bacteria 
grown  from  a  Culture  taken  from  the  infection  that  is  to  be 
treated.  An  autogenous  vaccine  has  the  advantage  over  a 
stock  vaccine  by  being  perfectly  fresh.  And  an  autogenous 
vaccine  is  not  only  a  vaccine  of  the  causative  organism,  but 
of  the  particular  strain  of  that  organism  that  is  causing  the 
infection.  Bacteria,  like  all  living  things,  are  influenced  by 
environment  as  to  their  finer  physical  manifestations,  no 
two  individuals  are  exactly  alike,  no  two  infections  are  ever 


VACCINES  171 

exactly  alike  even  though  caused  by  the  same  organism. 
Since  the  influences  upon  the  growth  and  physical  condi- 
tions of  the  bacterial  organisms  differ,  the  same  bacteria 
from  lesions  in  different  individuals  must  differ  in  some  re- 
spect or  other.  The  result  is  a  variety  of  strains  in  each 
form  of  bacteria.  Probably  this  minute  difference  is  of  no 
consequence  as  far  as  the  specific  mechanism  of  defense 
which  they  stimulate  is  concerned.  However,  this  minute 
difference  may  be  cumulative  and  in  the  process  of  evolu- 
tion a  later  strain  may  slowly  acquire  such  different  charac- 
teristics that  it  will  exert  a  specific  influence  upon  the  de- 
fensive mechanism. 

And  it  is  under  such  circumstances  that  a  stock  vaccine, 
although  of  the  bacteria  in  demand,  may  differ  essentially 
from  the  causative  organism  in  its  antibody  stimulation. 
Even  a  polyvalent  vaccine,  although  composed  of  many 
strains  of  the  same  bacteria,  may  altogether  have  missed  the 
particular  strain  required,  or  may  contain  so  few  bacteria 
of  this  particular  strain,  that  it  is  not  sufficient  to  produce 
the  desired  effect. 

The  variation  in  strains  is  best  illustrated  in  the  strep-  Especially  in 
tococcus  which  offers  an  opportunity  to  see  the  varied  out-  thecaseof 

streptococcus 

ward  manifestations  of  the  infection  it  produces,  although   »s  it  necessary 
the  temperature  curve  and  the  general  constitutional  effects  vaccine  of  the 
may  be  similar.     Thus  it  may  produce  a  streptococcus  septi-   same  s*rain  . 
cemia,  or  an  erysipelas;  at  another  time  we  may  have  .an  causing  the 
acute  arthritis,  scarlatina,  etc.     These  strains  of  the  strepto- 
coccus may  vary  so  distinctly  that  we  have  given  them  dif- 
ferent names  according  to  their  physical  manifestations,  as 
for  instance:  the  streptococcus  viridens,  streptococcus  hemo- 
liticus,  streptococcus  erysipelas,  streptococcus  ficalis,  etc. 

At  the  present  time,  we  can  obtain  stock  for  any  one  of 
these  particular  strains  ;  but  to  make  a  diagnosis  of  the  strain 
at  hand,  in  order  to  be  able  to  specify  the  stock  we  are  to 
use,  we  must  in  many  instances  employ  the  help  of  a  labora- 
tory. It  might  therefore  be  wiser  to  utilize  the  laboratory 


172  TUBERCULIN  AND  ^7'ACCINE 

for  the  making  of  the  autogenous  vaccine  since  the  main 
reason  for  the  employment  of  the  stock  is  the  fact  that  a 
great  many  physicians,  especially  in  the  small  towns,  have 
no  laboratory  within  convenient  reach.  The  expense  item 
is  no  longer  to  be  taken  into  consideration  since  the  cost  of 
making  autogenous  vaccines  ihas  greatly  diminished  in  the 
last  few  years,  and  many  State  laboratories  are  furnishing 
them  free. 

Of  course,  haste  must  not  be  an  excuse  for  choosing  stock 

vaccine;  for  where  there  is  the  necessity  for  haste,  there  is 

Manufacture        always  the  greater  necessity  for  accuracy.    We  can,  however, 

of  bacterial         administer  stock  vaccine  pending  the  making  of  the  auto- 
vaccine, — 
stock  or  genous  vaccine. 

the°iels  delay"  ^-n  OI>dering  a  vaccine,  we  (must  remember  that  in  its 

between  taking     manufacture  the  more  the  bacteria  retain  of  their  charac- 

the  culture  •      •  v      i         i        «      i  i  -i 

from  the  teristics,   both  physical  and  morphological,  the  greater  the 

thl'compietion     therapeutic  value  of  the  vaccine.     It  is  therefore  necessary 
of  the  finished      to  place  the  inoculated  culture  tube  at  body  temperature  as 

product,  the  ...  ,.  M  ,      .  -,  111 

more  active  soon  alter  inoculation  ;as  possible  in  order  to  enable  the  mak- 
ing of  the  subcultures  twenty-four  hours  later.  Longer 
growth  of  the  original  culture  may  modify  the  causative 
organism  by  too  long  a  contact  with  the  products  of  meta- 
bolism of  the  other  organisms  which  might  be  growing  vin 
the  same  culture  tube  through  accidental  contamination. 

In  making  subcultures,  we  must  remember  that  the  more 
The  more  concentrated  the  vaccine,  the  smaller  the  bulk  for  each  inoc- 

thev^cTne,         dilation.     Thus   sufficient   subcultures   should  be  made  in 
the  smaller  is       order  to  make  sure  that  there  is  sufficient  growth  for  a  high 

the  bulk  to  be  .  . 

inoculated.  concentration  without  the  necessity  for  longer  growth  than 
twenty-four  hours.  In  short,  the  less  time  that  intervenes 
between  the  original  inoculation  of  the  culture  tube  and  the 
completion  of  the  vaccine,  the  better  the  vaccine  will  be. 


CHAPTER  IV 
TREATMENT   OF  MIXED  IXFECTIOXS 

It  is  best  to  consider  mixed  infection  apart  from  the  classification: 

tubercular  process  when  dealing  with  the  use  of  vaccines  in  infections: 

its  treatment,  and  in  so  doing  classify  the  infections  into  *'  ^"Jne 

two  distinct  groups :  the  acute  and  the  chronic.     The  sub-  a  Chronic 

.,,-,,-,.  Infections. 

acute  group  need  not  be  separately  considered  when  dealing 
with  infection  in  relation  to  immunotherapy,  for  the  treat- 
ment is  the  same  for  the  sub-acute  as  it  is  for  the  chronic. 
However,  the  acute  form  is  best  subdivided  into  two  groups : 
the  febrile  and  the  afebrile. 

Mixed  respiratory  infections  have  to  be  considered  under 
a  special  topic  (Part  III,  Chapter  V)  as  their  treatment 
differs  somewhat  from  the  treatment  of  surgical  infections. 

Acute  Mixed  Infections 

Acute  Febrile  Mixed  Infections.  From  the  nature  of 
things  as  they  hold  true  in  acute  febrile  infections,  one 
would  assume  that  vaccine  would  be  useless  in  such  condi- 
tions. This  being  essentially  a  treatise  on  tuberculin  treat- 
ment, we  cannot  go  into  the  theories  and  detailed  descriptions 
of  conditions  existing  in  febrile  affections  to  refute  the  fre- 
quent assumption  that  vaccines  are  useless  and  even  danger- 
ous in  these  conditions.  But  for  the  purpose  of  avoiding 
unintelligible  gaps  in  this  important  subject,  I  shall  simply 
add  the  following  remarks  to  what  has  already  been  said  in 
the  theoretical  part  of  this  book : 

Vaccine  in  the  quantity  administered  for  the  purpose  of  vaccines 

.--     ,  .«,»..  T.       do  not  add 

treatment  is  not  toxic,  hence  we  do  not      add  toxins  to  the  toxicity  to  the 
body  which  is  already  saturated  with  toxins."     Vaccines   indlvldual- 
merely  stimulate  antibody  formation  at  the  site  of  inocula- 
tion even  in  the  presence  of  a  general  infection.     And  al- 
though fever  indicates  a  maximum  amount  •  of  resistance, 


174  TUBERCULIN  AND  \TACCINE 

forming  a  condition  unfavorable  to  bacterial  growth, — it  is 
true,  nevertheless,  that  we  have  periods  of  lowered  tempera- 
ture between  the  heights  of  the  curve,  representing  periods  of 
exhaustion.  The  period  of  exhaustion  forms  a  condition 
entirely  favorable  to  bacterial  growth,  during  which  the 
antibodies  coming  from  a  new  source  can  do  much  to  hold 
the  infection  in  check. 
Vaccines  Thus  if  we  will  consider  the  administration  of  vaccine 

stimulate  the 

formation  of  in  febrile  infection  as  an  aid  to  the  natural  protective 
mechanism,  and  if  we  mean  to  bring  that  aid  when  it  is 
needed, — in  other  words,  if  we  are  to  gauge  the  administra- 
tion of  vaccine  so  that  its  maximum  effect  will  come  during 
the  periods  of  depression,  we  shall  succeed  in  holding  the 
enemy  in  check  during  the  exhaustion  period. 

To  be  more  exact, — the  vaccine  should  be  administered 
The  relation        about  an  hour  or  two  after  the  height  of  the  temperature 
administration     curve  for  the  day  has  been  reached.     Thus  it  has  the  greater 
c°urvrPeratUre     ljart  of  twenty-four  hours  to  exert  its  influence  before  the 
next  temperature  peak  is  reached.     The  immune  response 
usually  occurs  within  six  to  twelve  hours  after  an  inocula- 
tion.    A  supply  of  antibodies  will  thus  be  provided  during 
a  period  in  the  temperature  cycle  when  the  patient's  own 
resistance  is  at  the  lowest  point. 

The  influence  of  the  vaccine  will  then  be  noticeable  on 
the  following  day's  temperature  cycle.  A  (minimum  amount 
of  time,  therefore,  need  elapse  before  we  shall  know  whether 
this  dose  and  the  following  dose  of  vaccine  was  effective  or 
not,  for  if  the  dose  happened  to  be  insufficient,  there  will  be 
no  reduction  in  the  temperature  peak  the  following  day,  and 
a  second  inoculation  should  be  given  an  hour  or  two  after 
the  height  of  temperature  has  been  reached. 

What  is  true  with  regard  to  the  time  of  administration 
is  also  true  of  the  intervals  between  inoculations.     The  in- 


guide  to  the  tervals  have  to  be  properly  gauged  to  get  the  best  results. 
Here  again,  by  means  of  the  temperature  curve,  we  are  able 
to  judge  the  intervals  most  accurately.  Once  a  temperature 


TREATMENT  OF  MIXED  IXFECTIOXS 


175 


curve  has  been  reduced  by  vaccine,  we  are  able  to  wait  for 
the  next  dose  until  the  temperature  begins  to  show,  by  a 
tendency  to  recur,  that  the  effect  of  the  previous  dose  is 
wearing  off.  jFrom  here  on,  the  intervals  between  the  inocu- 
lations should  be  equal  to  the  length  of  time  between  the  one 
injection  and  the  day  before  the  recurrence  of  temperature 
took  place. 

DOSAGE 


Bacteiia 


Beginning  Dose 


Amount  of 
Increase 


Streptococcus  25  million  10  million 

(  Albus 

Staphylococcus  -s  Aureus  100  million  25  to  50  million 

I  Citreus 

Colon  Bacillus  50  million  10  to  25  million 

B.  Pyocyaneus  100  million  25  million 

In  acute  febrile  infections  we  do  not  often  deal  with   vaccines  for 
more  than  one  bacteria  beside  the  tubercle  bacillus.    A  simple   multiple  acute 
vaccine  will  therefore  suffice  in  the  treatment  of  such  an   ' 
infection.     However,  if  more  than  one  organism  is  found 
to  be  the  cause  of  the  infection,  it  is  better  to  have  a  separate 
vaccine  for  each.     For  example,  if  a  streptococcus  and  a 
colon  are  found,  the  proper  dose  of  each  can  be  mixed  in  the 
syringe  and  administered  in  one  injection. 

It  is  best  to  treat  the  acute  mixed  infection  and  to  ignore   vaccine 

•    treatment  in 

the  tubercular  process  until  the  temperature  has  come  down    relation  to 
to  normal.     That  holds  true  whether  the  infection  is  present    tuberculm. 

A  treatment  in 

before  tuberculin  has  been  administered,  or  whether  it  occurs  febrile  acute 
during  a  course  of  tuberculin  treatment.  In  the  latter  case, 
the  interruption  of  the  tuberculin  treatment  cannot  mate- 
rially affect  the  tubercular  process,  as  acute  febrile  infec- 
tions do  not  last  long,  especially  when  treated)  with  vaccine. 
Once  the  temperature  has  come  down  to  normal,  tuber- 
culin administration  may  be  resumed  even  though  there  still 
remains  the  indication  for  further  vaccine  treatment.  We 
must,  however,  gauge  our  vaccine  inoculations  so  that  they 
fall  at  least  twentv-four  hours  before  tuberculin  is  adminis- 


170 


TUBERCULIN  AND  VACCINE 


3  C  C  C  a  (* 
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o-t-j  5  >-^  p 


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TKEATMENT  OF  MIXED  INFECTIONS      177 

tered,  or  forty-eight  hours  after  tuberculin  was  administered. 
The  administration  of  vaccine  at  the  same  time  or  too  near 
the  tuberculin  administration  niight  interfere  with  the  inter- 
pretation of  the  tuberculin  reaction. 

Before  leaving  the  subject  of  acute  febrile  mixed  infec-   The  correct 
tion,  I  must  emphasize  the  importance  of  accurately  differ-   between  • 
entiating  between  a  febrile  condition  brought   about  by  a    mixed  infection 

temperature 

sudden  activation  of  the  tubercular  process,  and  a  febrile   and  a 
condition  brought  about  by  a  mixed  infection.     In  an  acute   temperature 
condition  caused  by  the  tubercle  bacillus,  the  uselessness  of  >»  essential, 
a  vaccine  made  from  an  avirulent  organism  is  apparent.    On 
the  other  hand,  much  harm  can  result  from  a  failure  to 
institute    the   proper   vaccine    treatment    against    an    acute 
febrile   infection  occurring  during  a   course   of  tuberculin 
treatment  by  attributing  the  temperature  rise  to  an  exten- 
sion of  the  tubercular  process,  or  to  a  tuberculin  reaction. 

Acute  Afebrile  Mixed  Infections.  When  an  infection 
is  acute,  as  evidenced  by  the  acute  local  manifestations,  and 
still  produces  no  constitutional  manifestations  such  as  tem-  Definition, 
perature  with  its  accompanying  symptoms,  we  have  one  of 
two  conditions.  Either  there  is  an  acute  inflammation  bal- 
anced by  a  high  degree  of  resistance,  with  absorption  of  the 
inflammatory,  bacterial,  or  cellular  products,  in  quantities 
too  small  to  cause  constitutional  symptoms ;  or  else  there 
exists  a  point  of  exit  for  the  inflammatory  products  other 
than  by  means  of  the  circulation.  This  exit  may  be  drain- 
age through  an  incision,  or  suppuration ;  or  through  sinuses 
or  fistulas;  or  through  natural  channels,  such  as  the  ureter, 
urethra,  bronchial  tubes  and  so  on.  The  following  dosage 
has  been  found  satisfactory  in  most  instances: 

DOSAGE 

Amount  of 
Bacteria  Beginning  Dose  Increase 

Streptococcus  50  million     10  to  20  million 

j  Albus     1 
Staphylococcus  A  Aureus    V  150  million     25  to  50  million 

(  Citreus  J 

12 


ITS  TUBERCULIN  AND  VACCINE 

Colon  Bacillus  50  million  25  million 

B.  Pyocyaneus  100  million  25  million 

The  time  of  administration  is  no  factor  in  the  treatment 
of  afebrile  conditions,  as  there  are  no  periodic  fluctuations 
between  the  infection  and  the  patient's  resistance.  How- 
ever, as  regards  intervals,  a  measure  of  accuracy  must  be 
applied.  But  not  having  the  guidance  of  a  temperature 
Time  and  curve,  we  must  be  governed  entirely  by  subjective  or  objec- 

intervai  of  ^ve  symptoms.  Thus  if  there  is  no  improvement  in  forty- 
administration  eight  hours,  the  patient  should  be  reinoculated  if  the  mini- 
mum dose  was  used  in  the  first  place.  ,The  intervals  may  be 
determined  after  improvement  has  taken  place,  by  waiting 
with  further  treatment  until  a  tendency  for  the  recurrence 
of  the  symptoms  appears.  The  vaccine  treatment  is  then 
continued  without  again  waiting  for  the  recurrence  of  symp- 
toms, but  by  administering  the  reinoculations  one  day  before. 
The  objective  and  subjective  signs  which  act  as  guides  for 
the  determination  of  intervals  and  effects  of  the  vaccine 
treatment  in  general  are :  pain,  tenderness,  swelling,  redness, 
increased  or  diminished  motion,  the  character  and  quantity 
of  the  inflammatory  discharges,  and  so  on. 

If  a  reaction  occurs  immediately  after  an  inoculation, 

as  evinced  by  increased  symptoms  (negative  phase)  the  vac- 

Production          c^lie  treatment  should  be  discontinued  until  all  signs  of  the 

of  a  negative        reaction  have  disappeared.     Usually,  there  is  a  period  of 

phase  should  .  *   n         •  ,  .  ,  .    ,      . 

be  avoided.  improvement  following  such  a  reaction,  which  is  more  pro- 
nounced than  the  improvement  following  treatment,  without 
the  production  of  a  negative  phase.  However,  we  should 
not  purposely  produce  a  negative  phase  for  that  would  tend 
to  the  production  of  a  permanent  negative  phase  with  its 
attendant  dangers.  The  dose  of  vaccine  following  a  tran- 
sient negative  phase  should  not  be  increased;  however,  it 
need  not  be  diminished,  as  it  is  unusual  for  the  same  dose 
to  produce  a  negative  phase  more  than  once.  And  when  a 
negative  phase  does  occur,  it  will  be  transient  and  therefore 
beneficial. 


TREATMENT  OF  MIXED  INFECTIONS  179 

After  the  subsidence  of  the  acute  symptoms  it  is  advis-   Conclusion 
•  •  •         •         -i       of  vaccine 

able  to  continue  the  vaccine  treatment  for  a  time,  in  order  treatment 

to  inaintain  the  immunity  gained  against  the  mixed  infec- 
tion. For  this  purpose  it  is  sufficient  to  administer  one  dose 
of  vaccine  a  week,  continuing  with  slight  increase  for  sev- 
eral weeks  after  all  traces  of  infection  have  passed. 

The  element  of  time  is  frequently  just  as  important  in 
cases  of  afebrile  conditions  as  it  is  in  cases  of  febrile  mixed   stock  or 
infections.     So  that  it  may  be  advisable  to  use  simultane-  vaccfnes°US 
ously  a  vaccine  for  each  of  the  organisms  found.     However, 
in  the  majority  of  instances,  (it  is  practicable  to  use  ia  vac- 
cine for  the  preponderant  organism  first,  and  only  then  con- 
sider vaccines  for  the  remaining  organisms  if  the  treatment 
with  the  first  vaccine  proved  unsatisfactory. 

The  tuberculin  treatment  can  be  continued  without  inter- 
ruption during  the  vaccine  treatment  of  acute  afebrile  mixed   vaccine 
infections.     However,  if  the  mixed  infection  is  of  such  an  in  relation 
acute  nature  that  rapid  extension  of  the  disease  is  threatened,  *°  t"berc'1lm 

'     treatment  in 

and  if  shorter  intervals  than  one  week  are  indicated  for  the  afebrile 
vaccine  inoculations,  one  treatment  a  week  with  tuberculin 
would  be  sufficient  until  the  mixed  infection  is  under  control. 
The  vaccine  treatment  of  mixed  infections  in  tubercular 
conditions  has  been  observed  to  be  more  successful  in  tuber- 
culin  treated  patients  than  in  patients  not  treated  with  tuber- 

culin.     This  may  find  explanation  in  the  fact  that  tuberculin  reaction  is 

.         <»  •         i    •         i         *     *"  aid  to 
produces  a  hyperemia  at  the  point  01  inoculation  through    vaccine 

the  focal  reaction,  offering  greater  facility  for  the  ready  treatment- 
access  of  the  artificially  stimulated  immune  products,  to  the 
organisms  causing  the  infection. 


Chronic  Mixed  Infections 

Chronic  infection  from  the  standpoint  of  immunology  is  Definition. 
a  state  of  equilibrium  between  the  onslaught  of  the  invading 
organism  and  the  defense  of  the  host.     This  equilibrium  is 
maintained  by  means  of  various  mechanisms.     On  the  part 
of  the  bacteria,  the  failure  to  advance  may  be  due  to  a  los? 


ISO  TUBERCULIN  AND  VACCINE 

of  virulence,  or  to  an  inability  to  penetrate  the  fibrous  bar- 
rier which  the  host  has  built  around  the  infection  (incap- 
sulation). 
The  formation  Qn  the  part  of  the  host,  a  failure  to  entirely  overcome 

of  chronic  .  „    .  . 

infections.  the  invader  may  be  due  to  an  insufficient  immune  response; 

to  a  mechanical  obstruction  to  circulation  caused  by  a  high 
coagulability  of  the  serum  carrying  the  defensive  substances, 
thus  clogging  the  tissue  spaces  and  impeding  the  further 
arrival  of  antibodies;  and  to  an  insufficient  carrier  of  the 
products  of  the  immune  response  to  the  invading  organism. 
The  last  is  due  to  the  occurrence  of  anemia  instead  of  hyper- 
emia  at  the  point  of  infection.  This  anemia  may  be  brought 
about  either  by  a  state  of  the  blood,  or  by  mechanical  obstruc- 
tion to  the  circulation  at  or  near  the  point  of  infection  in 
the  form  of  a  defensive  capsule  to  stay  the  advance  of  the 
infection.  Thus  the  very  instrument  of  defense  (defensive 
capsule)  may  become  so  formidable  that  connective  tissue 
cannot  penetrate  through  it.  The  formation  of  a  permanent 
canal  (sinus  or  fistula),  or  cavity,  or  both,  takes  place  in 
which  the  invader  can  live  and  multiply  in  comparative 
security  shielded  from  the  immune  bodies  of  the  host. 

This  deadlock  between  infection  and  resistance  may  be 
maintained  by  a  number  of  other  causes  which  we  need  not 
discuss  in  further  detail  at  this  time.  [But  it  is  necessary 
to  have  at  least  a  cursory  understanding  of  the. elements  of 
chronic  infection  in  order  to  effect  its  final  elimination. 
chronicity  Xowhere  is  chronic  infection  so  chronic  as  in  tubercular 

pronounced  in  bone  diseases,  for  the  tubercular  process  tends  to  form  cavi- 
ties in  which  the  infective  material  gathers,  causing  the  for- 
mation of  fistulas  through  which  the  contents  of  the  cavities 
are  discharged. 

Where  the  equilibrium  between  the  resistance  of  the 
host  and  the  virulence  of  the  invader  is  the  sole  cause  of 
chronic  infection,  vaccine  alone  is  sufficient  to  cure  such 
a  condition.  For  with  vaccine,  we  are  able  to  add  sufficient 
antibodies  to  those  naturally  formed  to  break  the  deadlock 


TKEATMEXT  OF  MIXED  INFECTIONS  181 

in  favor  of  the  host,  and  at  once  accomplish  a  cure.     But  The  treatment 

.  ,        ,,  ff.    .  °l  pathological 

where  other  elements   aside  irom  the  msumcient   immune  changes 

response  are  the  cause  of  the  chronic  infection,  such  as  fis-  t^chrontcit11* 

tulas  and  cavities  and  so  on,  we  must  look  for  appropriate  must  be 

1ln.i  .  T   i       i        r>       -i  T         •  considered 

methods  besides  vaccines  to  accomplish  the  final  eradication  apart  fr 


om 


of  a  chronic  process.     Such  methods  will  be  described  under  ^e  treatment 

*  of  the 

Bone  Cavities,  Sinuses  and  Fistulas.  infection. 

The  dosage,  as  well  as  the  increases,  are  somewhat  higher 
in  chronic  conditions  than  in  acute  conditions. 

DOSAGE 

Amount  of 
Bacteria  Beginning  Dose  Increase 

Streptococcus  100  million                 25  million 

C  Albus  ] 

Staphylococcus  •<  Aureus  V  200  million                50  million, 

(Citreus  J 

Colon  Bacillus  100  million  25  to  50  million 

B.  Pyocyaneus  150  million  25  to  50  million 

One  treatment  a  week  is  most  convenient  and  usually 
sufficient,  but  it  must  be  so  timed  as  not  to  interfere  with 
the  determinations  of  the  bi-weekly  inoculations  of  tuber- 
culin. 

A  chronic  infection  in  a  tubercular  subject  constitutes 
a  suitable  condition  for  the  study  of  the  mode  of  action,  and   Vaccines 
of  the  effects  of  vaccines.     The  character  of  the  cases,  and  mul 
the  length  of  time  required  for  a  course  of  tuberculin  treat-  chronic 

0  ^  m  infectionS 

ment  offers  a  long  enough  period  for  any  method  of  vaccine 
treatment  we  may  find  appropriate  to  apply.  Thus  I  have 
found  that  in  the  long  run  the  use  of  vaccine  against  one 
organism  at  a  time  in  cases  of  multiple  infection,  not  only 
produces  better  results  but  offers  the  best  conditions  in  which 
to  determine  the  exact  role  which  each  organism  plays  in 
mixed  infection.  For  instance,  if  we  have  a  streptococcus 
and  a  staphylococcus  albus  and  a  staphylococcus  aureus  in 
a  mixed  infection,  by  making  an  autogenous  vaccine  for  the 
streptococcus  or  by  using  a  stock  streptococcus  vaccine,  we 


182  TUBERCULIN  AND  VACCINE 

can  study  by  culture  and  by  smear  the  effect  of  these  vac- 
cines on  such  infections. 

If,  after  the  streptococcus  vaccine  has  been  used  for  a 
reasonable  length  of  time,  and  if  the  streptococcus  disappears 
from  the  discharge  without  producing  any  appreciable  effect 
either  quantitatively  or  on  its  consistency,  we  can  be  reason- 
ably sure  that  the  staphylococcus  aureus  or  the  staphylococ- 
cus  albus  or  both  have  been  active  in  the  formation  of  the 
infection,  and  will  require  rthe  specific  vaccines  for  their 
irradication.  If,  however,  the  discharge  thins  and  becomes 
sterile  after  the  use  of  the  streptococcus  vaccine,  it  is  at 
once  evident  that  the  staphylococcus  merely  existed  in  the 
discharge  in  a  parasitic  form,  or  formed  a  coincident  surface 
infection  during  the  taking  of  the  cultures  while  the  real 
offender  was  the  streptococcus  alone. 

By  this  method,  besides  saving  time,  expense,  and  trouble 
for  the  patient,  we  obtain  a  grasp  upon  vaccine  therapy  that 
no  other  method  offers. 

Of  course,  the  necessity  of  working  with  cultures  and 
smears  may  appear  too  complicated  a  task  for  the  busy  gen- 
eral practitioner.  However,  the  whole  matter  may  be  made 
very  simple  and  may  even  add  another  element  of  interest 
to  his  work. 

The  growing  of  cultures  may  be  accomplished  by  the 
simple  procedure  described  in  Chapter  II,  Part  III.  Smears 
may  be  made  on  ordinary  slides  (which  can  be  easily  ob- 
tained) by  first  placing  a  drop  of  water  on  the  slide;  the 
material  to  be  examined  is  stirred  up  in  this  drop  of  water 
and  spread  in  a  thin  film,  allowed  to  dry  in  the  air,  and  fixed 
in  the  flame.  The  process  of  staining  is  still  simpler. 
Loefler  methylene  blue  is  all  that  is  required.  A  few  drops 
are  placed  on  the  smear  for  one  minute,  then  rinsed  off 
with  ordinary  tap  water,  and  after  the  slide  dries  the  smear 
is  ready  for  examination  under  the  microscope. 

To  make  matters  still  simpler,  nature  has  endowed  the 
pyogenic  bacteria  with  very  easily  distinguishable  features. 


TREATMENT  OF  MIXED  INFECTIONS      183 

For  example,  the  streptococcus  is  easily  recognized  by  its- 
chain  formation;  while  the  staphylococcus  grows  in  groups. 
The  albus,  aureus,  and  citreus  can  be  distinguished  from 
their  different  appearances  in  the  culture  tube.  The  albus 
is  white,  the  aureus  a  golden  yellow,  and  the  citreus  a  lemon 
yellow.  And  the  colors  are  so  distinct  that  there  is  no  room 
for  doubt  as  to  their  identity.  (Chapter  II,  Part  III.) 


CHAPTER  V 

MIXED  INFECTIONS  IN  PULMONARY 
TUBERCULOSIS 

Mixed  Mixed    infections   in   pulmonary   tuberculosis  .differ   so 

respiratory  radically  from  mixed  infections  in  other  processes,  both  in 
conlLTs^oT  tne^'  pathological  forms  and  in  their  symptoms,  that  it  is 
wjse  fo  gO  fnto  a  little  more  detail  on  the  subject  rather  than 


and  catarrhal  .  .  m  . 

processes.  to  include  it  under  the  general  heading  of  mixed  infections. 

As  was  stated  in  the  preceding  chapter,  a  mixed  infection 
merely  means  an  infection  [with  an  organism,  or  organisms, 
superimposed  upon  and  helping  to  continue  the  tubercular 
process.  It  rarely  assumes  an  unusual  form.  In  respira- 
tory conditions,  however,  the  mixed  infection  organism  may 
not  only  exaggerate  the  usual  symptoms  of  pulmonary  tuber- 
culosis, and  animate  the  tubercular  process,  but  may  produce 
symptoms  entirely  apart  from  the  tubercular  process.  Such 
infections  may  be  sufficiently  acute  to  be  more  dangerous  to 
life  than  the  tubercular  process  itself;  they  may  upset  all 
the  beneficial'  results  obtained  with  tuberculin,  and  render 
the  condition  hopeless. 

Weather  Again,  we  must  bear  in  mind  what  a  tremendous  influ- 

and  c'atarrhai  ence  weather  conditions  have  upon  a  tubercular  process  in 
processes  in  the  lungs  ;  for  the  intimacy  that  exists  between  the  various 

the  upper  air  jf      i  « 

passages  exert  parts  of  the  respiratory  system  is  self-evident.  An  acute 
i^nutncTupon  rhinitis  may  alter  the  aspect  of  a  tubercular  lung  condition, 
pulmonary  and  a  streptococcic  sore  throat  ,may  do  for  the  pulmonary 

tuberculosis.  ,  . 

process  what  measles  will  do  in  any  tubercular  condition  in 
the  child. 
The  following  In  a  condition  of  mixed  infection  in  pulmonary  tuber- 

three  distinct  ,...  nr>    •  i  i  • 

situations  for  culosis  it  is  not  sumcient  merely  to  make  a  vaccine  of  the 
offending  organisms,  but  we  pmust  consider  its  application 

exist:  with  reference  to  three  distinct  situations:  First,  the  use  of 

vaccine  in  co-existing  mixed  infections  which  add  to  the 


MIXED  INFECTIONS  IN  PULMOXAKY  TUBERCULOSIS    185 
chronicitv  of  the  process  as  they  do  in  all  other  forms  of 

mixed 

tuberculosis:  second,  an  acute  or  subacute  infection  co-exist-  infections; 

ing  with  the  tubercular  process,  interfering  with  or  nullify-  subacute 

ing  entirely  the  immune  response  to  tuberculin;  third,  and  "f*"^1.. . 

most  important,  the  use  of  vaccines  in  prophylactic  immuni-  ?•  Prophylactic 

1  immunization 

zation,  during  periods  of  the  year  when  catarrhal  inflamma-  against  preva- 
tion,  such  as  influenza,  bronchitis,  etc.,  are  prevalent. 

It  is  ideal  when  dealing  with  so  complex  a  problem  as 
immunization  in  respiratory  mixed  infections  to  have  the 
patient  in  bed  under  constant  professional  supervision,  with 
a  well  equipped  laboratory  and  trained  laboratory  assistants,   For  practical 
to  make  daily  observations  as  to  the  effect  of  the  vaccines   thTmost0' 
injected,  and  of  the  change  in  the  organisms  present.     The  Prominent 

bacteria  need 

percentage  of  physicians  who  have  such  facilities  is  so  small  be  considered 
that  we  cannot  even  dignify  their  number  with  the  name  of  t°l^"r^ 
minority.  Those  who  have  these  facilities,  and  are  taking 
advantage  of  them,  are  rendering  a  great  service  by  clearing 
many  of  the  complexities  connected  with  the  subject,  making 
it  possible  for  us  to  utilize  their  experience  to  some  extent 
in  our  practical  application,  however  limited  the  field  may 
yet  be.  For  the  vast  majority  of  physicians  who  do  not 
have  these  (facilities,  it  is  fortunate  that  we  are  easily  able 
to  find  at  least  the  most  important  organisms  by  simpler 
methods,  and  treat  the  patients  with  a  fair  measure  of 
success. 

Since  this  book  is  intended  as  a  guide  to  the  utilization 
of  the  immune  response  within  the  limitation  of  practical 
application,  I  shall  avoid  enlarging  upon  methods  which  can 
be  carried  out  only  by  means  of  modern  laboratory  facilities. 

The  number  and  variety  of  bacteria  that  may  be  found 
in  respiratory  secretions  is  of  necessity  large  because  of  the 
easy  access  that  any  bacteria  has  to  any  part  of  the  respira- 
tory tract.  Xot  only  are  the  canals  open,  but  we  directly 
invite  the  entrance  of  these  organisms  by  inhalation,  by  the 
partaking  of  food,  and*  by  the  deep  recesses  that  can  harbor 
bacteria  and  allow  them  to  grow.  Yet,  not  all  bacteria  found 


TUBERCULIN  AND  VACCIXE 


Even  in  the 
presence  of  a 
large  variety 
of  bacteria, 
treatment  for 
the  strepto- 
coccus, 

penumococcus, 
and  the  m. 
catarrhalis  is 
sufficient  in 
most  cases. 


in  the  respiratory  tract,  even  during  disease,  are  pathogenic; 
and  when  we  have  an  infection  in  the  respiratory  tract  it 
is  very  difficult  to  determine  which  of  the  organisms  are  at 
fault.  However,  some  of  them  are  commonly  at  fault. 

In  the  treatment  of  respiratory  infections  existing  in  a 
tubercular  individual,  we  must  be  content  to  make  a  vaccine 
of  one  or  more  of  the  easily  recognized  and  easily  cultivated 
bacteria  that  we  find.  Fortunately  this  will  embrace  a 
large  enough  class  of  cases  to  make  it  worthy  of  trial. 

The  variety  of  organisms  at  fault  is  relatively  small  in 
cases  of  mixed  infections  in  tubercular  lungs.  We  find  by 
experience  that  the  streptococcus  in  a  tubercular  lung  is 
most  often  concerned  with  the  production  of  the  added  in- 
fection, whereas  the  staphylococcus  is  found  to  be  the  most 
frequent  offender  in  infections  in  a  non-tubercular  lung. 
By  using  an  autogenous  vaccine  of  the  streptococcus  found 
in  the  sputum  of  a  pulmonary  tubercular  patient,  we  very 
often  clear  the  mixed  infections  to  such  an  extent  that  it 
need  not  be  reckoned  with  (any  further  in  the  treatment  of 
the  tubercular  condition.  The  staphylococcus  is  of  course 
a  frequent  offender.  The  pneumococcus  takes  the  third 
place.  Less  frequently  do  we  Jiave  to  deal  with  the  micro- 
coccus  catarrhalis,  the  influenza  bacillus,  the  Friedlander 
bacillus,  and  the  micrococcus  tetrogenus,  except  in  prophy- 
lactic immunization  during  prevalent  catarrhal  infections. 
I  have  left  other  organisms  out  of  consideration,  because  of 
the  difficulty  of  isolation,  and  the  frequency  with  which 
they  disappear  from  the  sputum  after  using  the  vaccines 
against  the  other  organisms. 


Chronic 
respiratory 
mixed 
infections 
are  of  two 
varieties: 
i.    Infections 
superimposed 


Chronic  Respiratory  Mixed  Infections 

The  chronic  infections  form  the  greatest  majority  of 
mixed  infections  in  pulmonary  tuberculosis,  and  in  their 
consideration  we  must  recognize  two  distinct  types.  The  in- 
fection which  implants  itself  upon  a  tubercular  area  as  it 
does  in  bone  and  gland  tuberculosis ;  and  the  catarrhal  infec- 


MIXED  INFECTIONS  IN  PULMONAKY  TUBERCULOSIS     187 


tion  which  prepares  the  soil  for  the  tubercle  bacillus.  The 
former  requires  treatment  only  when  we  find  that  it  aggra- 
vates the  tubercular  infection  or  interferes  with  the  benefits 
derived  from  the  tuberculin.  The  mere  finding  of  bacteria 
in  the  sputum  is  pot  sufficient  a  reason  to  consider  the  use 
of  vaccines  necessary. 

However,  we  have  a  more  difficult  problem  to  deal  with 
in  the  treatment  of  primary  mixed  infections  which  resisted 
the  process  of  natural  immunity  and  treatment  for  a  great 
many  years,  and  which  produced  trauma  in  the  lung,  and 
attracted  the  tubercular  infection  in  the  lung  in  the  same 
manner  as  direct  trauma  attracts  the  tubercle  bacillus  in  a 
case  of  bone  and  joint  disease.  Here  we  must  not  lose  sight 
of  the  various  pathological  changes  that  many  years  of  catar- 
rhal  infection  have  brought  about  in  the  lung  and  bronchial 
tubes.  These  changes  must  be  reckoned  with  in  our  expec- 
tations as  to  the  results  to  be  obtained  from  immunotherapy. 

Mixed  Infections  Which  Follow  Upon  a  Tubercular 
Process.  The  number  of  bacteria  that  may  implant  them- 
selves upon  a  tubercular  process  in  the  lung  is  very  large 
and  varied.  The  direct  communication  between  the  nose  and 
mouth  and  lungs  makes  this  possible.  Fortunately  not  all 
the  bacteria  are  pathogenic  and  not  all  of  the  pathogenic 
bacteria  that  find  lodgment  in  the  tubercular  lung  get  beyond 
the  saprophitic  form.  Even  those  that  do  become  virulent 
and  help  in  the  pathological  changes  brought  about  by  the 
tubercular  process  naturally  become  extinct  during  the  heal- 
ing process  of  the  tubercular  infection,  and  so  require  no 
special  attention. 

However,  during  the  treatment  of  the  tubercular  condi- 
tion, any  of  these  pathogenic  bacteria  may  get  deeper  lodg- 
ment and  produce  symptoms  which  will  cause  a  drain  upon 
the  system.  The  progress  against  the  tubercle  bacillus  will 
thus  be  interfered  with  unless  treatment  aiming  to  eradicate 
the  mixed  infection  is  instituted.  Since  the  streptococcus 
is  the  most  frequent  offender  in  pulmonary  mixed  infec- 


upon  the 
tubercular 
process; 
2.    Primary 
infections 
which  created 
the  traumatic 
condition,  and 
which  attracted 
the  tubercle 
bacillus. 


The  tubercular 
process  in  the 
lung  is 
particularly 
prone  to 
mixed 
infection. 


188  TUBERCULIN  AND  VACCINE 

tions,  a  vaccine  made  of  the  streptococcus  will  often  control 
all  the  annoying  symptoms  that  may  arise  to  interfere  with 
the  tuberculin  treatment.  Frequently,  the  catarrhal  types 
of  bacteria  become  just  as  annoying;  thus  the  micrococcus 
catarrhalis,  and  the  pneumococcus,  and  other  bacteria  occa- 
sionally demand  our  attention.  In  order  not  to  deviate  from 
the  practical  purpose  of  this  book,  I  shall  not  go  into  detail 
here  concerning  the  more  infrequent  infective  organisms, 
especially  as  such  bacteria  are  isolated  and  grown  with  diffi- 
culty. The  streptococcus  vaccine  will  cover  so  many  cases 
of  mixed  infection  that  by  means  of  this  vaccine  alone  much 
can  be  done  in  the  treatment  of  a  mixed  infection  super- 
imposed upon  a  purely  tubercular  process  in  the  lung. 

Primary  mixed  Mixed   Infections   Which   Act   as   Fertilizer   for  the 

most  difficult  Tubercular  Process.  Primary  mixed  infections  offer  a 
more  difficult  task  for  the  physician.  Here  we  have  a 
chronic  respiratory  infection  as  the  primary  pathological 
process  —  the  process  acting  after  the  manner  of  trauma  in 
hone  and  joint  infection  by  establishing  a  localized  loss  of 
resistance,  while  the  bacteria  act  as  fertilizer  for  the  growth 
of  the  tubercle  bacillus  when  once  the  tubercle  bacillus  lodges 
in  the  respiratory  tract. 

A  distinction  By  caref  ul  differentiation  between  the  various  signs  and 

be  made  symptoms,   we  can   distinguish  those   symptoms   which   are 

caused  bv  the  mixed  infection,  from  those  due  to  the  tuber- 

symptoms 

produced  by         cular  process.     Unless  this  differentiation  is  made,  the  phys- 
s^8'ns  ™  these  conditions  which  are  usually  spread  over 


those  produced     onc  or  even  over  ^h  lungs,  will  produce  the  impression  of 

by  the  mixed 

infection.  an  extensive  tubercular  process,  whereas  in  truth  only  a  be- 

ginning tubercular  infection  exists.  It  therefore  happens 
that  during  any  treatment  of  the  mixed  infection  which 
proves  effective,  the  tubercle  bacilli  may  disappear  from  the 
sputum,  leading  to  the  assumption  that  a  cure  of  the  tuber- 
cular process  has  been  accomplished. 

At   this   stage   the  patient   is   usually  discharged   from 
further  observation,  although  it  is  well  known  how  readily 


MIXED  INFECTIONS  IN  PULMONARY  TUBERCULOSIS  189 
a  chronic  respiratory  infection  will  return.  When  the  Treatmentof 

the  tubercular 

slightest  recurrence  of  the  chronic  infection  takes  place  the  process  is 

, .    .  ,  .,  .,.          often  relaxed 

tubercular  condition  recurs  because  the  hypersusceptibihty  on  account 
still  remains.    In  this  class  of  cases  we  have  the  great  army  "nterpre'tation 
of  sufferers  who  are  not  alarmed  at  their  condition  because  of  the  dis~ 

appearance 

of  the  long  standing  of  their  infection.     They  take  their  con-  of  symptoms 
dition  seriously  only  when  tubercle  bacilli  are  found  in  their   due  to  the" 
sputum.     A  change  of  climate,  and  more  favorable  hvgienic,   m'xed 

"  °  '     infections. 

dietetic  treatment,  quickly  improve  these  patients.  They 
then  return  to  their  regular  habits  and  occupations,  only 
soon  to  fall  victims  to  a  recurrence.  The  chronicity  of  the 
mixed  infection  thus  goes  hand  in  hand  with  the  chronicity 
of  'the  tubercular  infection,  the  pendulum  swinging  back 
and  forth  between  apparent  cure  and  evident  recurrence 
until  they  finally  succumb  to  the  slowly  progressive  tuber- 
cular infection,  or  to  an  acute  exacerbation  of  the  disease. 

The  tuberculin  treatment  of  these  patients  we  have 
already  discussed  in  ^Chapter  VI,  Part  II.  If  we  add  vac- 
cine treatment  for  the  mixed  infection,  we  are  able  to  raise 
the  resistance  of  these  patients  to  a.  degree  that  will  permit 
a  thorough  eradication  of  the  tubercular  process.  Since 
tuberculin  also  removes  the  hypersusceptibility,  a  recurrence 
is  thus  in  a  great  measure  prevented.  Of  course  the  ideal 
treatment  is  a  combination  of  immunotherapy  with  climatic 
treatment,  but  when  circumstances  will  allow  only  one  of 
the  two  methods,  immunotherapy  must  be  chosen.  The 
increasing  of  resistance  through  immunotherapy  in  spite  of 
the  patient's  surroundings  will  produce  permanent  results, 
whereas  a  return  to  former  conditions  after  an  improvement 
gained  through  a  change  in  climate  will  prove  more  rapidly 
detrimental  than  when  those  conditions  contributed  to  the 
production  of  the  original  condition. 

The  chronic  infections  which  prepare  the  soil  for  the 
advent  of  the  tubercle  bacillus  may  be  any  one  of  the  chronic 
infections  that  exist  in  the  respiratory  tract,  such  as  chronic 
bronchitis,  bronchial  asthma,  unresolved  pneumonia  and  all 


100  TUBEECULIX    AND    VACCINE 

catarrhal  conditions  that  form  pathological  changes  in  any 
of  the  respiratory  passages.  The  bacteria  that  are  most  at 
fault  here  are  the  streptococcus,  micrococcus  catarrhalis,  the 
pueumococcus,  m.  paratetrogenus,  Friedlander  B.,  bacillus 
influenza,  staphylococcus  albus  and  aureus. 

The  medical  Treatment.     The  medical  treatment  and  the  hygienic 

respiratory          dietetic  treatment  must  be  carefully  carried  out  in  chronic 
mixed  mixed  infections,  whether  the  mixed  infection  was  the  cause 

infections  is 

important.  of  the  tubercular  process,  or  came  as  a  result  of  it.     The 

indiscriminate  use  of  drugs  should  be  avoided  especially  in 
the  case  of  narcotics  or  creosote.  Creosote,  when  wrongly 
used,  is  capable  of  a  great  deal  of  harm,  and  yet,  should  not 
be  dispensed  with,  for  it  is  equally  capable  iof  a  great  deal 
of  good  when  applied  in  the  proper  condition  and  in  the 
proper  dosage.  We  should  familiarize  ourselves  with  the 
physiological  action  and  proper  indications  for  the  use  of 
this  drug  before  prescribing  it. 

The  vaccine  The  dosage  of  vaccines  is  the  same  in  all  chronic  condi- 

tions. Fifty  million  of  the  streptococcus  should  be  given 
as  a  beginning  dose,  increased  by  about  twenty  million  for 
the  following  three  or  four  doses  and  if  there  seems  to  be 
no  beneficial  effect — as  would  be  noted  by  a  decrease  in 
amount,  or  a  change  in  character  of  the  sputum,  or  by  an 
evident  decrease  of  the  streptococcus  in  the  sputum — the  last 
dose  should  be  doubled  and  then  continued'  at  the  same  rate 
of  increase  as  before. 

The  micrococcus  catarrhalis  and  B.  Friedlander  best 
administered  in  doses  of  twenty-five  million,  increased  'by 
five  or  ten  million  for  each  of  the  subsequent  four  'or  five 
doses  and  if  need  be,  the  fourth  or  fifth  dose  can  be  doubled 
to  get  a  more  positive  effect. 

The  beginning  dose  of  the  m.  paratetrogenus  should  be 
fifty  million,  increased  by  from  ten  to  twenty  million  at 
each  subsequent  dose. 

The  pneumococcus  and  b.  influenza  should  be  adminis- 
tered in  the  same  dosasre  as  the  m.  catarrhalis. 


MIXED  INFECTIONS  IN  PULMONAKY  TUBERCULOSIS     191 


The  staphylococcus  albus  and  aureus  should  be  admin- 
istered in  a  dose  of  two  hundred  million  in  the  beginning, 
with  subsequent  increases  of  twenty-five  to  fifty  million,  with 
the  same  doubling  of  the  fourth  or  fifth  dose  if  it  should  be 
necessary. 

TABLE  OF  DOSAGE 


Streptococcus 
M.  Catarrhalis 
B.  Friedlander 
M.  Paratetrogenus 
Pneumococcus      , 
B.  Influenza 

|  Albus 
Staphylococcus  < 

(  Aureus 


Beginning  Dose 

50  million 

25  million 

25  million 

50  million 

25  million 

25  million 


Increase 

20  million 

5  to  10  million 

5  to  10  million 

10  to  20  million 

5  to  10  million 

5  to  10  million 


200  million     25  to  50  million 


Before  tuberculin  treatment  is  instituted  it  is  advisable  Treatment  of 
to  treat  the  chronic  infection  with  vaccines  until  it  is  under  infection  before 
control.    About  three  or  four  weeks  of  treatment  will  usually  tuberculin 

*     treatment. 

suffice  to  get  the  chronic  infection  under  control,  and  then 
tuberculin  treatment  should  be  instituted.  However,  we 
must  make  certain  that  where  vaccine  treatment  is  instituted 
before  the  tuberculin  treatment,  the  acute  condition  is  not 
due  to  the  tubercular  infection.  The  tuberculin  treatment 
should  not  be  delayed  in  cases  where  the  tubercular  process 
has  produced  a  great  deal  of  wasting. 

In  case  of  a  multiple  mixed  infection  and  if  the  patient 
is  in  fair  physical  condition,  it  is  best  to  administer  a 
separate  vaccine  of  each  organism  on  different  days  rather 
than  to  treat  the  patient  with  all  of  the  vaccines  at  the  same 
time.  For  the  purpose  of  illustrating,  let  us  assume  that 
the  streptococcus,  the  m.  catarrhalis,  and  the  pneumococcus 
are  the  principal  offenders.  The  streptococcus  vaccine  can 
be  administered  on  Monday,  the  catarrhalis  vaccine  on 
Wednesday,  and  the  pneumococcus  vaccine  on  Friday.  A 
more  clear  cut  immune  response  can  thus  be  obtained,  and 


192  TUBERCULIN  AND  VACCINE 

a  more  accurate  observation  can  be  imade  of  the  effect  of  each 
vaccine. 

In   chronic  mixed   infections  which  become  implanted 
upon  a  tubercular  area,  vaccines  need  not  ibe  used  until  the 
tuberculin  treatment  has  been  administered  for  two  or  three 
Treatment  of       months.     The  reason  is  the  same  as  for  the  application  of 
inf'eTtlon6  vaccines  before  tuberculin  in  primary  mixed  infections.   The 

during  improvement  of  the  primary  condition  through  any  agency 

treatment.  will  exert  a  beneficial  effect  on  a  secondary  process.    Through 

the  treatment  of  the  tubercular  process  which  is  here  pri- 
mary, the  mixed  infection  process  may  be  so  favorably  in- 
fluenced that  it  may  require  no  treatment.  The  local  hyper- 
emia  produced  by  the  tuberculin  focal  reaction  is  sufficient 
tn  overcome  the  mixed  infection,  especially  as  the  chronicity 
of  the  process  has  robbed  the  causative  bacteria  of  their 
virulence. 

However,  should  the  mixed  infection  persist  in  spite  of 
improvement  in  the  tubercular  process,  its  treatment  should 
be  undertaken  by  the  use  of  a  vaccine  against  the  most  promi- 
nent organism  found  in  the  sputum.  Later,  a  vaccine  against 
each  of  the  other  organisms  that  persist  in  the  sputum  should 
be  used,  if  no  improvement  has  taken  place  from  the  pre- 
vious vaccine.  In  the  same  manner  several  vaccines  may  be 
Tried  in  turn  until  the  mixed  infection  is  no  longer  a  factor 
in  the  production  of  symptoms.  These  vaccines  should  be 
administered  once  a  week,  and  so  timed  that  they  do  not 
interfere  with  the  tuberculin  reaction. 


Acute  Respiratory  Mixed  Infections 

Acute  respiratory  infection  occurring  in  a  patient  with 
An  acute  mixed    pulmonary  tuberculosis  forms  a  most  berious  condition  of 

infection  in  a  /«    .  . 

tubercular  affairs,  since  an  acute  infection  has  the  tendency  to  greatly 

lower  the  resistance  of  the  patient  to  tuberculosis.  When 
acute  infection  occurs  in  the  same  organ,  it  not  only  raises 
the  hypersusceptibility  to  a  marked  degree,  but  also  encour- 
ages a  local  extension  of  the  tubercular  process. 


MIXED  INFECTIONS  IN  PULMONARY  TUBERCULOSIS     193 

So  it  happens  that  a  lesion  erstwhile  progressing  favor- 
ably under  tuberculin  treatment  may  be  suddenly  invaded 
by  an  acute  respiratory  infection  which  lights  up  the  tuber- 
cular process  to  such  a  degree  that  it  passes  beyond  control. 
Fortunately,  in  prophylactic  immunization  we  have  a  means 
by  which  the  danger  of  an  occurrence  of  acute  infection  can 
be  greatly  minimized.  But  when  it  does  occur  we  must 
unite  all  the  resources  at  our  command  to  tide  the  patient 
over  the  acute  attack.  Since  vaccine  forms  at  least  as  im- 
portant a  measure  as  any  other,  it  is  the  duty  of  every  physi- 
cian to  utilize  it  under  such  urgent  circumstances. 

In  dealing  with  acute  pulmonary  infections  complicat-  Acute  mixed 
ing  tuberculosis,  two  distinct  (types  should  be  recognized :  the  aVof'tvro 

acute  infections  which  are  acute  exacerbations  of  a  chronic   varieties: 

i.  Acute  ex- 
infection,  and  the  fresh  acute  infections  that  are  epidemic,   acerbations 

Under  the  former,  we  are  dealing  mainly  with  pyogenic   infec'ticn"10 
organisms  producing  such  conditions  as  pulmonary  abscess,   2-  Fresh  acute 

1  or  epidemic 

empyema,  and  pneumonic  processes.     Under  the  second  class,   infections, 
we   deal   mainly   with   catarrhal   bacteria   producing  lacute 
"  colds,"  influenza,  and  so  on. 

Treatment.     Aside  from  immunotherapy  for  acute  con-   Treatment  of 
ditions  in  pulmonary  tuberculosis,  we  can  add  but  little  to   acutemi*ed 

"  infection  in 

the  present  day  accepted  methods  of  treatment.  However  respiratory 
mild  the  acute  infection  may  be,  rest  in  bed  is  absolutely 
imperative.  Appropriate  drugs,  proper  food  and  proper 
elimination  are  equally  important.  However,  a  wider  expe- 
rience with  immunotherapy  will  not  only  demonstrate  its 
value  as  an  additional  aid  in  the  treatment  of  acute  respira- 
tory infections,  but  the  reduction  in  the  frequency  of  the 
occurrence  of  acute  infection  through  prophylactic  immuni- 
zation will  become  apparent. 

During  the  vaccine  treatment  of  acute  conditions  it  is   interrupt 
best   to  interrupt   the   tuberculin   administration  while   the  treaYmenT 
process  is  still  acute.     The  increased  hypersusceptibilitv  that   during  the 

>«/J  r_  treatment 

occurs  as  a  result  of  the  acute  infection  may  bring  about  a   of  acute 
constitutional  reaction  which,  being  masked  by  the  symp- 
13 


1'J-i 


TUBERCULIN  AND  VACCINE 


torn?  of  the  acute  mixed  infection,  would  lead  to  a  further 
inciease  in  the  dose  of  tuberculin,  and  bring  about  a  disas- 
trous result.  After  such  an  interruption,  the  tuberculin 
treatment  should  be  resumed  with  a  dose  considerably 
smaller  than  the  last  dose  previous  to  the  acute  infection. 

The  bacteria  most  concerned  in  acute  infections  are:  the 
pneumococcus,  M.  catarrhalis,  M.  tetrogenus,  B.  septus,  B. 
influenza,  the  staphylococeus,  and  the  streptococcus. 


TABLE  OF  DOSAGE 

Beginning  Dose 


Increase 


The  tempera- 
ture curve  is 
the  best  guide 
to  dosage  and 
intervals  of 
vaccine 
treatment. 


Pneumoeoccus 

M.  Catarrhalis 
M.  Tetrogenus 
B.   Septus 
B.  Influenza 
Streptococcus 


25  million       5  to  10  million 


20  to     40  million  10  million 

{Aureus   ~| 
V  100  to  150  million 
Albus      J  25  to     50  million 

In  the  treatment  of  acute  infections  with  vaccines  we 
have  the  temperature  curve  as,  the  best  guide  to  dosage  and 
intervals.  A  careful  temperature  record  will  show  at  the 
end  of  twenty-four  hours  whether  the  dose  was  insufficient, 
or  whether  an  overdose  was  used  and  a  negative  phase  pro- 
duced. The  vaccines  of  all  the  offending  organisms  should 
be  administered  in  each  inoculation,  unless  the  infection 
definitely  points  to  one  or  more  of  the  bacteria  as  being  the 
sole  cause,  in  which  case  these  alone  should  be  used  and  the 
reft  ignored. 

One  example  is  the  pneumococcus :  If  the  sputum  shows 
an  abundance  of  the  pneumococcus,  a  vaccine  of  the  pneumo- 
coccus  will  be  sufficient  even  though  other  bacteria  may 
appear  in  the  smear;  the  same  holds  true  of  the  influenza 
bacillus.  However,  if  the  streptococcus  or  the  M.  catar- 
rhalis appear  with  the  two  above  mentioned  bacteria,  it  can 


INFECTIONS  IN  PULMONARY  TUBERCULOSIS     195 

do  no  harm,  nor  can  it  jeopardize  the  beneficial  effects  de- 
rived from  ;the  use  of  the  influenza  or  pneumococcus  vaccine 
if  we  add  the  minimum  doses  of  streptococcus  or  M.  catar- 
rhalis  vaccines.  After  the  acute  symptoms  are  passed,  it  is 
advisable  to  continue  the  use  of  the  vaccines  for  several 
months  at  weekly  or  two-weekly  intervals. 

Prophylactic  Immunization  Against  Mixed 
Infections 

Vaccines  have  no  better  field  than  in  prophylactic  im-  Prophylactic 

.,.»,.  .  -,  ,     -,  immunization 

mumzation  against  mixed  iniections  in  pulmonary  tubercu-  against  mixed 
losis.     We  all  know  the  importance  of  protecting  these  suf-  infections 

.  .        plays  an 

ferers  against  weather  changes  and  against  exposure  to  rain  important 
and  dampness.     We  also  realize  that  the  object  in  carrying  j^tmelt'of 
out  these  measures  of  protection  is  to  prevent  a  temporary  pulmonary 

,  .    ,  .      , .     .  ,  /     tuberculosis. 

lowered  resistance,  which  would  render  the  individual  sub- 
ject to  a  new  bacterial  invasion,  or  to  an  acute  exacerbation 
of  chronic  infection. 

But  what  is  the  success  of  these  measures  ?  In  spite  of 
all  that  is  done,  there  are  so  many  chances  for  the  patient 
to  be  caught  off  guard,  that  only  few  escape  an  infection  in 
the  respiratory  tract  during  the  treatment  of  the  tubercular 
condition.  Prophylactic  immunization  greatly  reduces  the 
dangers  of  infection  ,by  raising  the  resistance  to  the  bacteria 
to  such  a  degree  that  even  if  it  is  not  sufficient  to  prevent 
infections  altogether,  it  certainly  wrill  prove  effective  in  com- 
bination with  the  usual  measures  of  prevention. 

The  importance  of  prophylactic  immunization  against 
mixed  infection  cannot  be  sufficiently  emphasized.  Among 
the  greatest  achievements  in  medicine,  that  brought  about  by 
prophylactic  immunization  stands  preeminent — I  need  but 
mention  the  prevention  of  typhoid  fever  alone,  to  call  forth 
a  realization  of  the  possibilities  of  prophylactic  immuniza- 
tion. The  written  medical  annals  of  the  present  great  war 
will  contain  no  less  a  staggering  array  of  superwonclers 
brought  about  by  medical  and  surgical  skill,  than  those 


196  TUBERCULIN  AND  VACCINE 

accomplished  by  the  engineer  or  general.  And  prophylactic 
immunization  against  all  forms  of  infection  will  be  found 
to  have  played  a  startling  part  in  the  formation  of  these 
annals.  I  say  startling,  because  the  greater  part  of  the  med- 
ical profession  that  still  scoff  at  vaccine  therapy  in  general, 
will  suddenly  wake  up  to  the  fact  that  they  have  been  hope- 
lessly left  behind. 

The  following  Prophylactic    immunization    consists    of    two    distinct 

prophylactic        forms:  that  which  aims  to  prevent  epidemic  infections,  and 
immunization      ^hat  ^yhich  aims  to  prevent  acute  exacerbations  of  infections 

should  be  <  f 

considered:         the  bacteria  of  which  are  present  in  the  sputum. 

i.  Prophylactic          Prophylactic  Immunization  Against  Epidemic  Infec- 

immunization  .  it         i      i       *  •       •  •       ,•  •  •  i         •.'••' M 

against  tions.     Prophylactic  immunization  against  epidemic  miec- 

epidemic  tions   is    as  simple   as    prophylactic   immunization   against 

infection.  ,    «- 

typhoid,  except  that  we  have  more  than  one  bacteria  to  deal 
with.  As  in  typhoid,  (three  inoculations  with  a  stock  vac- 
cine are  administered  a  week  apart,  and  in  the  following 
doses : 

First  dose          Second  dose        Third  dose 
Pneiimococcus 
B.  Influenza 

M.  Catarrhalis 

'      .   .,,      1      L          100  million     200  million     300  million 
B.  Jb  riedlander 

Streptococcus 
(Salivarius) 

A  bottle  of  stock  vaccine  (holding  from  five  to  twenty 
cubic  centimeters)  should  be  obtained  of  each  bacteria.  A 
concentration  of  at  least  1,000  million  bacteria  per  cubic 
centimeter  should  be  insisted  upon,  thus  avoiding  too  bulky 
an  inoculation  for  the  third  dose. 

The  five  bacteria  need  not  be  combined  into  one  vaccine 
and  administered  at  one  time.  If  it  is  found  expedient,  we 
may  divide  them  into  two  groups  and  administer  one  group 
on  one  day,  and  the  other  group  on  another  day,  keeping  a 
record  of  the  administration  of  each  so  that  the  reinocula- 
tions  may  be  continued  at  weekly  intervals. 


MIXED  INFECTIONS  IN  PULMONARY  TUBERCULOSIS     197 
Prophylactic  Immunization  Against  Acute  Exacerba-  2-  Prophylactic 

.       .  .  .  immunization 

tions.     Prophylactic  immunization  aimed  to  prevent  acute  against  acute 


exacerbations  of  infections,  the  bacteria  of  which  are  present      exutig 
in  the  sputum,  is  not  quite  as  simple  as  the  prophylactic  chr°nic 

.         .  .  .  ,         ...  infections. 

immunization  against  epidemic  injections,  as  it  requires  a 
microscopic  study  of  the  sputum  in  order  to  determine  the 
bacteria  against  which  immunization  is  necessary.  How- 
ever, the  amount  of  knowledge  that  is  required  for  practical 
purposes  can  be  acquired  without  much  difficulty.  The 
organisms  that  need  be  considered  in  this  connection  can 
easily  be  distinguished  after  a  short  reference  to  any  book 
on  bacteriology,  especially  Allen  on  "  Bacterial  Diseases  of 
Respiration."  The  organisms  consist  of  one  or  more  of  the 
following  bacteria,  and  should  be  administered  according 
to  the  accompanying  dosage: 

First  dose 
Pneumococcus 
M.  Paratetrogenus 


M.  Cattarrhalis 
Streptococcus 

(Salivarius) 
B.  Friedlander 


50  million,  increased  weekly  by  25 
million 


One  inoculation  a  week  is  sufficient,  but  inoculations 
should  be  continued  for  a  longer  period  than  in  the  case  of 
prophylactic  immunization  where  the  bacteria  are  not  present 
in  the  sputum. 

In  the  estimation  of  the  value  of  prophylactic  immuni- 
zation we  must  consider  the  length  of  the  period  of  immunity 
that  is  conferred  by  the  various  infectious  organisms.     It  is  The  length 
well  known  that  these  periods  differ  greatly  with  the  differ-  bacteria  are 
ent  infections.     For  instance,  the  bacteria  producing  measles  e*^^*f 

conferring  an 

confers  a  life  immunity;  in  the  case  of  typhoid,  the  period  immunity 

,          i  •       ,  i  c    i  •    i  ,  i        •        ii         should  serve 

seems  to  be  about  seven  years ;  in  the  case  01  diphtheria,  the  as  a  guide 
use  of  prophylactic  antitoxins  seems  to  protect  for  about  six  *°r«- 

L       L     '  ...  immunization. 

weeks  only,  and  so  on  through  the  various  infections.     Un- 


198  TUBERCULIN  AND  VACCINE 

fortunately  the  length  of  immunization  acquired  as  a  result 
of  respiratory  infections  seems  to  last  no  longer  than  two  or 
three  months.  Therefore,  it  is  necessary  to  repeat  the  pro- 
phylactic immunization  once  or  twice  during  the  period 
between  September  and  May.  For  example,  if  a  prophy- 
lactic immunization  is  administered  in  September,  it  is  ad- 
visable to  repeat  the  inoculations  in  December  and  again  at 
the  end  of  February. 

General  Prophylaxis 

The  disregard  The  consideration  of  prophylactic  measures  apart  from 

pro™hpy0jacat"c        vaccines  does  not  come  under  the  province  of  this  work,  but 

I  find  that  the  neglect  of  prophvlactic  measures  is  so  fre- 

particularly 

noticeable  in        qncntlv  a  source  of  failure  in  immunotherapy  that  I  cannot 
of  pulmonary       dismiss  the  subject  without  calling  attention  to  its -impor- 
tance.     The   more   recent   adoption   of  prophylaxis   of   the 

This  is  true  L 

not  only  in  moil th  and  teeth  and  nasopharynx  into  general  prophylaxis 

cTses  buTy          a^so  Deserves  more  attention  than  it  receives  at  the  hands  of 

the  general  practitioner;  especially  when  its  main  obiect  is 

seated  in  \  .  J 

many  public  to  remove  common  sources  of  reinfection.  Here  also  we 
shall  take  into  consideration  the  elimination  of  pathological 
processes  which  so  frequently  occur  in  obscure  recesses  and 
occupy  such  small  areas  that  they  escape  the  notice  of  the 
patient  as  well  as  of  the  physician.  The  consideration  of 
dietetic  measures,  not  only  from  the  standpoint  of  nutrition, 
but  what  is  more  important,  from  the  standpoint  of  assimi- 
lation, must  be  here  included  as  well  as  the  important  ele- 
ments of  rest  and  exercise. 

Attention  to  Elimination  of  Sources  of  Infection.     One  of  the  prin- 

the  nose,  . 

throat,  and  cipal  contributions  to  the  knowledge  of  medicine  in  the  last 
decade  has  been  the  discovery  that  pathological  dental  pro- 
cesses, pathological  changes  in  the  tonsils  and  in  the  nasal 

conditions  ,  ,,  ,. 

•vhich  are  pharynx  form  important  factors  in  the  production  of  chronic 

luentiy    ,lisea>e,  and  that  the  elimination  of  these  factors  is  essen- 

of  mixed  tial   to  the  total   eradication  of  chronic  infections.      Since 

tuberculosis  is  the  most  universal  of  the  chronic  infections, 


INFECTIONS  IN  PULMONARY  TUBERCULOSIS     199 

these  pathological  processes  demand  as  much  attention  when 
they  ocur  in  a  case  of  pulmonary  tuberculosis  as  in  any 
other  chronic  infection.  A  thorough  examination  of  the 
teeth  and  gums  by  a  competent  dentist,  including  X-ray 
examinations  of  the  dental  processes  and  of  the  roots,  is  a 
necessary  adjunct  to  the  successful  treatment  of  tuberculosis. 

The  bacteriological  study  of  tonsils  removed  from  other- 
wise healthy  children  has  sufficiently  demonstrated  the  fact 
that  the  tonsils  are  not  only  very  often  the  source  of  mixed 
infections,  but  the  source  of  the  tubercular  process  as  well. 

The  nasopharynx,  including  the  sinuses  and  antrums,  is 
a  frequent  source  of  mixed  infections.  We  may  not,  how- 
ever, institute  indicated  surgical  measures  such  as  the  re- 
moval of  adenoids,  the  removal  of  tonsils,  the  removal  of 
hypertrophied  turbinates,  etc.,  until  the  tubercular  infection 
has  been  checked.  But  during  the  treatment  of  the  tuber- 
cular process  we  must  institute  such  measures  as  will  elim- 
inate their  negative  influence  on  the  favorable  progress  of 
the  disease. 

We  often  cannot  dispense  with  the  dentist  in  spite  of  the 
poor  circumstances  of  the  patient,  but  we  are  able  to  admin- 
ister such  medical  treatment  for  the  various  conditions  in 
the  nasopharynx,  etc.,  that  in  these  conditions  we  can  for 
the  time  being,  at  least,  dispense  with  the  help  of  a  specialist. 
Of  course  it  would  be  ideal  to  have  a  specialist  co-operate 
with  us  in  the  treatment  of  these  conditions,  but  the  majority 
of  us  deal  with  a  class  of  patients  that  cannot  afford  any 
extra  expense,  and  a  large  number  of  general  practitioners 
who  practice  in  the  rural  districts  are  beyond  the  reach  of 
the  specialist. 

A  nasal  spray  composed  of  twenty  grains  of  menthol, 
twenty  grains  of  camphor,  a  few  drops  of  oil  of  cinnamon 
in  an  ounce  of  liquid  vaseline  will  do  a  great  deal  to  improve 
the  breathing  and  is  as  good  a  mucous  membrane  anti- 
septic as  we  have.  Add  to  this  a  five  to  twenty  per  cent, 
argyrol,  and  our  armamentarium  is  complete  for  the  control 


200  TUBERCULIN  AND  VACCINE 

of  most  of  the  conditions  that  may  exist  in  the  upper  air 
passages.  Other  medicaments  for  local  application  or  for 
internal  use  may  be  found  of  value  for  special  conditions. 
For  further  detail  .the  reader  is  referred  to  the  proper  au- 
thorities on  the  subject. 

Personal  Personal    Hygiene.     Personal  hygiene  of  the   patient 

nTifst'bl  embraces  daily  care  of  the  mouth  and  teeth  and  frequent 

insisted  bathing  to  enlist  the  proper  function  of  the  skin.     Let  me 

upon. 

mention  here  that  the  matter  of  encouraging  bathing  is  of 
great  importance,  as  the  fallacy  exists  among  the  laity  that 
the  bath  is  detrimental  to  the  sufferer  from  phthisis  by 
exposing  him  to  colds.  He  should  be  encouraged  to  live 
under  proper  conditions,  a  clean  room,  proper  ventilation 
and  many  other  fine  details  that  are  not  only  beneficial  from 
the  hygienic  standpoint,  but  help  to  divert  the  patient's  mind 
to  details  not  altogether  bearing  directly  on  his  disease. 
These  diversions  are  very  helpful.  I  mention  these  very 
familiar  points  in  the  hygiene  of  the  patient,  not  because 
I  need  to  call  attention  to  them, — that  is  hardly  necessary 
in  view  of  the  fact  that  the  importance  of  hygiene  in  tuber- 
culosis was  recognized  generations  ago  and  constitutes  prac- 
tically the  major  part  of  the  usual  treatment  of  tubercu- 
losis— but  in  order  to  call  attention  to  the  absolute  necessity 
on  the  part  of  the  physician  to  insist  upon  their  being  car- 
ried out.  Frequently  these  directions  for  hygiene  are  given 
to  the  patient  at  the  same  consultation  when  his  diagnosis  is 
made  and  when  the  patient's  mind  is  far  from  realizing  their 
importance.  Again,  the  patient  reads  and  hears  so  much 
about  hygiene  that  his  very  familiarity  with  the  subject 
causes  him  to  neglect  it.  The  physician  must  repeat  his 
directions  and  insist  on  absolute  compliance  with  them,  and 
refuse  the  treatment  of  any  patient  who  persists  in  neglecting 
them. 

Dietetics.  Dietetics  in  tubercular  individuals  has  been 
a  topic  of  controversy  for  many  years.  The  varied  opinions 
of  different  workers  in  tuberculosis  have  extended  from  rest 


MIXED  INFECTIONS  IN  PULMONABY  TUBEKCULOSIS  201 
in  bed  and  fluid  diet  to  the  extreme  of  forced  feeding.  I  Dietetics 

must  be 

believe  we  have  at  last  arrived  at  the  best  possible  method  regulated 
of  feeding  tubercular  patients.     Tuberculosis  is  a  disease  of   to  the 
long  standing  and  slow  wasting.     It  should  be  our  object  powers  o^t 
to  push  the  nourishment  to  the  maximum  point  of  tolerance ;    individual- 
but  absolutely  limited  by  the  amount  of  assimilative  powers 
of  the  individual.    As  soon  as  we  exceed  the  power  of  assimi- 
lation by  any  quantity  of  food,  we  throw  an  added  burden 
upon  the  already  over-taxed  system  by  forcing  it  to  dispose  of 
the  surplus.    And  since  the  circulation  must  be  drawn  upon 
in  order  to  dispose  of  any  surplus  food,  the  circulation  is 
diverted  in  an  undue  degree  to  the  gastro-intestinal  canal, 
and  an  anemia  is  created  at  the  point  of  infection.    Improper 
feeding  will  thus  interfere,  or  wholly  prevent  one  of  the 
main  assets  in  the  conquest  of  disease — hyperemia. 

It  is  not  difficult  to  estimate  a  patient's  assimilative 
powers.  Symptoms  like  distress  in  the  stomach,  fullness, 
sleepiness  and  dullness  in  the  head  after  meals,  languidness, 
all  point  to  over-feeding.  The  rapid  accumulation  of  fat 
should  not  be  looked  upon  without  apprehension.  Such  a 
gain  in  weight  does  not  indicate  a  gain  in  strength  and 
resistance.  On  the  contrary,  a  rapid  accumulation  of  fat 
such  as  is  indicated  by  a  rapid  gaining  of  weight  without 
an  increase  of  strength,  points  to  a  process  of  surplus  food 
disposal  which  some  patients  acquire  as  a  protection  against 
stagnation,  but  which  requires  an  unusual  drain  on  the  cir- 
culatory mechanism.  Hence  a  circulatory  insufficiency  at 
the  infected  area  is  followed  by  the  retrogression  that  is  so 
often  noticed  in  such  patients  under  the  least  adverse  cir- 
cumstances. Nourishing  food  and  well  masticated,  in  quan- 
tities easily  assimilated,  and  proper  bowel  action,  are  the 
essentials  of  proper  dietetics  for  the  tuberculous  individual. 

The  following  three  radiographs  of  pulmonary  conditions 
will  be  found  interesting  in  connection  with  diseases  of 
mixed*  infections.  They  represent  three  distinct  types  of 
tubercular  pulmonary  disease  modified  by  mixed  infection. 


202  TUBERCULIN  AND  VACCINE 

The  first,  Fig.  46,  represents  a  mild  tubercular  condition 
lasting  over  a  period  of  two  years  with  very  little  pulmonary 
destruction.  A  hemorrhage  was  the  first  sign  of  the  disease 
followed  by  a  persistent  but  mild  cough.  Bacilli  did  not 
appear  in  the  sputum  So  few  were  the  physical  signs  in 
the  lungs  that  my  diagnosis  of  pulmonary  tuberculosis  made 
at  the  time  of  the  hemorrhage  was  severely  criticized  and 
denied  by  five  physicians  under  whose  treatment  the  patient 
came  during  the  two  years.  At  the  beginning  of  the  third 
year,  the  cough  began  to  increase  and  became  productive  for 
the  first  time.  The  amount  of  expectoration  steadily  in- 
creased in  quantity  and  became  more  and  more  purulent  in 
consistency.  Abundant  tubercle  bacilli  were  now  demon- 
strated in  the  sputum,  a  circumstance  which  brought  the 
patient  back  under  my  care.  The  physical  signs  were  those 
that  point  to  the  condition  as  shown  in  the  X-ray  photo- 
graph. Fig.  46.  Although  both  apices  were  the  seats  of 
considerable  cavities,  the  rest  of  the  lungs  is  clear.  The 
mild  apical  lesion  became  the  seat  of  mixed  infection  with 
the  forma tion  of  a  true  abscess  in  each  upper  lobe,  causing 
rapid  disintegration  of  the  tubercular  tissue  and  remaining 
the  seat  of  a  constant  purulent  production.  Without  mixed 
infection  treatment,  tuberculin,  while  it  may  prevent  the 
spread  of  the  disease  beyond  this  localized  area,  cannot  stop 
the  pus  formation  in  the  cavities,  nor  distressing  symptoms 
which  it  produces. 

The  second.  Fig.  47,  represents  a  more  widely  distributed 
tubercular  process.  The  tubercular  infection  began  after  a 
grippe  infection;  the  cough,  which  was  mild,  persisted  for 
a  year  and  a  half  with  but  slight  expectoration.  The  patient, 
however,  lost  rapidly  in  weight  and  in  strength,  night  sweats 
were  persistent — in  short,  he  presented  a  typical  picture  of 
pulmonary  tuberculosis  of  the  slowly  progressing  type.  To- 
wards the  end  of  the  second  year  of  his  illness  an  attack  of 
grippe  brought,  about  alarming  symptoms  including  a  severe 
hemorrhage,  and  the  patient  was  removed  to  a  high  altitude 
where  after  three  months  of  treatment  and  rest  in  bed,  the 


• 


- 


MIXED  INFECTIONS  IN  PULMONARY  TUBERCULOSIS     203 

acute  symptoms  subsided,  but  the  amount  of  cough  and 
expectoration  increased  to  such  an  extent  that  it  interfered 
with  the  patient's  sleep,  and  frequently  brought  on  attacks 
of  vomiting.  The  patient  was  then  sent  to  Denver,  Colo- 
rado, where  he  gained  in  weight  and  improved  in  every  way 
except  in  the  amount  of  cough  and  expectoration.  He  re- 
turned and  applied  for  tuberculin  treatment  at  the  New 
York  Polyclinic  Hospital. 

As  will  be  seen  in  the  radiograph,  the  left  lung  is  the 
seat  of  a  cavity  in  the  upper  lobe  near  the  apex,  and  al- 
though there  are  small  foci  of  healed  tuberculosis  through- 
out, the  lung  is  the  seat  of  compensatory  emphysema.  The 
fact  that  there. is  a  contracting  cicatricial  form  of  healing 
in  the  left  lung  with  compensatory  emphysema  in  the  right, 
is  sufficient  evidence  that  the  patient  possesses  a  fair  amount 
of  recuperative  power.  But  the  mixed  infection  interferes 
to  the  greatest  extent  with  the  complete  arrest  of  the  process. 
Under  mixed  infection  treatment  and  tuberculin  adminis- 
trations, the  patient  has  improved  far  more  rapidly  than 
under  special  climate  and  sanitarium  treatment.  After  the 
first  month  of  immunotherapy  the  patient  returned  to  work 
and  has  never  lost  a  day  for  the  last  three  and  a  half  years. 

The  third,  Fig.  48,  illustrates  a  case  of  a  tubercular 
infection  following  upon  a  fertilized  field  prepared  by  a 
ten-year-old  chronic  bronchial  infection.  The  amount  of 
hypersusceptibility  was  never  high  so  that  the  tubercular 
process  was  never  acute.  The  following  is  a.  copy  of  the 
X-ray  report  made  when  the  patient  first  applied  for  im- 
munotherapy in  December,  1915. 

Radiographic  examination  of  your  patient,  X,  shows  a  marked 
degree  of  involvement  of  practically  all  of  both  fields.  There  are 
large  cavities  in  the  left  upper  lobe.  All  the  costal  cartilages  are 
markedly  calcified,  and  there  is  little  evidence  of  calcific  deposit  in 
the  pulmonary  fields. 

Doctor  Y. 

A  year  later  the  following  radiographic  report  was  made 
of  his  condition,  which  is  an  interpretation  of  the  third 
radiograph  here  illustrated  (taken  in  November,  1916). 


204  TUBERCULIN  AND  VACCINE 

Radiographic  examination  of  your  patient,  X,  shows  a  marked 
degree  of  clouding  and  infiltration  of  both  pulmonary  fields.  The 
upper  third  of  the  left  pulmonary  field  is  consolidated.  There  are 
bands  of  adhesions  and  a  portion  of  a  cavity  wall  in  the  middle 
of  the  left  pulmonary  field.  The  right  pulmonary  field  shows  a 
moderate  degree  of  compensatory  emphysema.  The  cardiac  shadow 
is  drawn  to  the  left. 

Doctor  Y. 

In  1913,  the  patient  had  a  very  serious  hemorrhage 
followed  by  a,  long  confinement  in  bed.  In  1915,  or  just 
prior  to  the  beginning  of  tuberculin  and  vaccine  treatment, 
the  patient  suffered  an  acute  exacerbation  of  the  mixed 
infection  with  high  temperatures,  causing  extreme  emacia- 
tion and  confinement  to  bed  for  two  months.  It  was  at 
the  earnest  solicitation  of  the  patient's  family  that  I  under- 
took his  treatment.  They  wanted  him  to  have  every  com- 
fort and  hope  for  the  last  months  of  his  life — the  patient 
being  fully  aware  of  the  hopelessness  of  his  condition.  His 
history,  together  with  an  examination  of  his  sputum,  re- 
vealed to  me  the  fact  that  a  mixed  infection  was  responsible 
for  the  most  distressing  symptoms — cough  which  was  rack- 
ing and  constant  especially  at  night,  and  expectoration  which 
was  purulent  and  very  profuse.  The  patient  ran  an  after- 
noon temperature  of  100.5  to  101.5. 

Improvement  commenced  after  two  months  of  treatment 
with  tuberculin  and  vaccine.  After  six  months  of  treat- 
ment, the  tubercle  bacilla  disappeared  from  the  sputum. 
The  cough  became  less  severe  during  the  day  and  disap- 
peared entirely  during  the  night.  Fig.  48  is  a  radiograph 
of  the  patient's  chest  at  the  conclusion  of  treatment.  The 
patient  is  greatly  improved  and  at  this  writing  (six  months 
later)  is  still  maintaining  his  improvement. 

A  comparison  between  the  two  reports  shows  a  definite 
structural  improvement  as  well  as  a  symptomatic  improve- 
ment. I  did  not  publish  both  radiographs  because  I  did 
not  intend  to  show  structural  changes  at  this  point,  I  merely 
publish  the  last  radiograph  in  order  to  show  that  even  in 
such  an  apparently  hopeless  condition,  the  combined  vaccine 
and  tuberculin  therapy  can  do  much  to  improve  a  patient. 


— 
0 

02 


CHAPTEE  VI 
SURGICAL  MEASURES 

To  be  absolutely  correct,  this  topic  should  be  headed 
"  Tubercular  Surgery,"  for  experience  has  revealed  the  fact 
that  surgical  principles  as  applied  in  general  surgery  do  not  Surgical 

principles 

apply   in   like  manner  in   tubercular   surgical    conditions,    must  be 
Hardly  a  day  passes  without  bringing  further  evidence  that   ^"          '" 


general  sureerv  when  applied  in  tubercular  conditions  does   app.hcatlon 

in  tubercular 

more  harm  than  good  and  sometimes  irretrievably  injures  the  conditions. 
patient.  One  main  reason  for  the  unique  situation  that  tuber- 
cular processes  offer,  from  the  surgical  point  of  view,  is  the 
fact  that  the  tubercle  bacillus  is  not  a  pyogenic  organism,  and 
that  its  infective  process  is  in  the  main  extremely  localized. 
The  action  of  the  tubercle  bacillus  is  entirely  local,  its  spread 
means  an  involvement  of  a  larger  area  but  still  localized.  It 
produces  no  effect  in  the  blood  circulation;  and  when  the 
tubercle  bacillus  does  get  into  the  circulation  it  may  lodge 
in  glandular  structure  distant  from  the  point  of  infection 
and  become  localized  there. 

All  this  occurs  very  slowly.  So  slowly,  *in  fact,  that  the 
natural  resistance  of  the  body  against  the  tubercle  bacillus 
is  able  to  localize  or  limit  the  infection.  And  it  is  only 
after  a  long  standing  immune  response  bringing  about  a  high 
grade  of  hypersusceptibility  that  we  may  get  a  general,  dis- 
seminated tuberculosis.  That  is  extremely  rare;  and  when 
it  does  occur,  we  know  that  it  comes  more  frequently  after 
radical  surgery  than  when  surgery,  however  necessary  and 
conservative,  has  been  altogether  withheld.  In  fact,  in  tuber- 
culosis, from  the  standpoint  of  surgery,  conditions  hold  true 
directly  opposite  to  those  that  apply  in  other  infections.  For 
instance,  in  other  infections  surgery  will  prevent  a  general 
septicemia,  and  will  prove  effective  in  proportion  to  the 
promptness  of  its  application.  In  tubercular  infections,  on 
the  contrary,  general  infection  occurs  in  direct  proportion 


200  TUBERCULIN  AND  VACCINE 

to  the  amount  of  surgery  applied.  Hence,  the  entire  negl'ect 
of  surgery  has  rarely  produced  a  general  dissemination  of 
the  infection. 

The  principal  The  whole  subject  of  surgery  in  tuberculosis  can  there- 

Iurtf«i  °r          fore  be  limited  to  its  application  as  a  .means  to  reduce  symp- 
toms and  prevent  extensive  localized  destruction.     In  fact; 
i.  The  preven-     t]ie  most  important  reason  for  its  application  is  for  cosmetic 

tion  of  undue 

destruction.  effects. 

ficadon™f°dl  Most  of  the  infected  areas  ,will  finally  break  down  and 

drain  by  means  of  fistulas.  However,  there  is  a  great  deal 
of  pain  until  that  occurs,  hence,  the  application  of  surgery 
for  the  purpose  of  forestalling  extensive  destruction  add  for 
the  amelioration  of  pain. 

On  the  other  hand,  we  must  not  overlook  the  importance 
of  proper  surgery  in  tubercular  conditions  for  cosmetic 
effects.  .Breaking  down  of  tubercular  processes  produces 
ugly  scars,  and  by  getting  ahead  of  such  breaking  down  with 
the  proper  surgical  interference,  we  may  prevent  the  forma- 
tion of  scars,  or  we  may  at  least  reduce  them  to  a  minimum. 

Nature's  The  extensive  operations  that  have  been  recently  devised 

icaHze  ail          ^or  restoration  of  function,  for  the  limitation  of  progres- 

tubercuiar  <ive  deformities,  or  for  the  removal  of  parts  where  the  de- 

infections  .  .  ... 

must  not  be         struction  has  gole  beyond  the  possibility  oi  restoration  of 

function,  should  be  applied  only  after  the  hypersusceptibility 
of  the  individual  has  been  removed  jby  a  course  of  tuberculin. 
In  this  way,  we  remove  all  possibility  of  the  extension  of 
the  process  beyond  the  radius  of  the  surgical  interference. 
In  other  words,  with  tuberculin  we  remove  the  constitutional 
element  of  the  disease,  and  by  limiting  the  process  to  a  local 
condition  we  endow  the  necessary  surgical  measures  with 
the  highest  degree  of  safety. 

In  order  to  successfully  apply  surgery  in  a  tubercular 
individual,  we  must  always  bear  in  mind  that  it  is  the  hyper- 
susceptibility  and  not  the  tubercle  bacillus  that  is  the  cause 
of  any  extension  of  the  process;  and  that  in  applying  sur- 
gery to  abscesses,  fistulas,  tubercular  glands,  etc.,  we  are 
doing  so  merely  to  produce  a  better  result  than  would  occur 


SUEGICAL  MEASURES  207 

by  natural  processes  alone.  To  sum  up,  if  we  wait  with  the 
major  surgery  until  we  have  eliminated  the  hypersuscepti- 
bility  with  tuberculin,  and  limit  the  surgical  measures  to 
the  treatment  of  the  resultant  local  tissue  changes,  we  will 
be  rewarded  with  a  commensurate  degree  of  success. 

Before   entering   upon    the   chapters    dealing    with    the   The  following 
surgical  treatment  of  tubercular  infections  of  glands,  bone,   tubercular 
etc.,  the  nature  of  the  various  processes  involved  in  cuber-  musfbTborne8 
cular  areas  must  be  clearly  understood.     These  consist  of   >«>n»»ndm 
the  following  four  distinct  forms:  surgical 

The  first  is  the  pure  tubercular  process  which  in  healing  ™CpSuurrees' 
becomes  absorbed,  disappearing  entirely  for  the  most  part,   tubercular 

n-,,  1-1  c  T  infiltration, 

Ine  second  is  the  process  of  cicatrization.     A  tubercular   leaving  no 
area  may  be  filled  in  with  connective  tissue  forming;  a  hard    gross  alteratlon 

on  healing; 

cicatrix.     This  may  or  may  not  become  impregnated  with   2.  Fibrosis, 
calcium  salts.     Depending  upon  the  extent  of  the  original   behind  Tmass 
process,  it  mav  on  healing,  leave  behind  an  area  of  altered  thesi2C°f 

"      .  which  is  in 

structure  which  if  near  the  surface,  forms  a  palpable  mass,   proportion  to 
The  third   is   a  tubercular  process  modified   by   mixed  the  ordinal* 
infection,  which  brings  about  a  slow  suppuration  with  pus  process; 

.  3.   Tubercular 

formation.  inflammation 

The  fourth  is  a  process  of  liquefaction  within  a  protec-  m1['"[dby 

tive  capsule  surrounding  the  original  tubercular  area.     This  infection; 

liquefaction  might  remain  unchanged  for  a  long  period.     It  tionpius 

is  known  as  "  cold  abscess."    However,  the  cold  abscess  may  ll(iuefactlon' 

<*     or  cold 

become  infected  and  change  to  the  suppurating  variety  by  abscess 
breaking  through  to  the  surface.  Again,  it  may  terminate 
by  the  secretion  from  the  cells  lining  the  wall  of  a  tryptic 
ferment,  which,  acting  as  a  digestant  upon  the  capsule  wall? 
and  finally  on  the  tissues  beyond,  breaks  upon  the  surface 
and  expels  its  contents. 

This  process  of  "  pointing  "  of  a  cold  abscess  through 
the  digestion  of  tissue  must  be  distinguished  from  the 
"  pointing  "  of  inflammatory  abscesses  through  suppuration. 
The  former  process  is  sterile,  therefore  much  slower;  and 
when  the  surface  is  approached,  there  is  a  direct  sloughing 
of  tissue  instead  of  mere  breaking  open  as  in  the  case  of 
ordinary  abscesses. 


CHAPTER  VII 

THE   SURGICAL  TREATMENT  OF  TUBERCULAR 

GLANDS 

Classification:  The  classification  of  glands  with  relation  to  their  surg- 

''  Q0lnf,!a^?na     ical  treatment  differs  from  the  classification  with  regard  to 

2.    oUppuraiing 

glands.  the  tuberculin  treatment.     Whereas  the  one  classification 

glands.  bears  upon  the  relation  of  glands  to  the  constitutional  mani- 

festation of  the  disease,  in  the  present  classification  we  must 
consider  the  nature  of  the  local  process  in  relation  to  local 
treatment.  Thus  we  distinguish  three  varieties:  the  soft 
glands,  the  suppurating,  and  the  cicatrized. 

Soft  Glands 

soft  glands  S0ft  glands  are  cold  abscesses.     The  gland  capsule  re- 

are  the  same  ..  i  .1        i  i  i  T          n    i     i 

in  structure         mains  intact  while  the  parenchyma  becomes  liquefied  dur- 
ing the  tubercular  process.     This  liquid  is  mucoid  in  char- 
abscesses. 

acter  and  is  interspersed  with  particles  of  caseous  material. 
The  older  this  cold  abscess,  the  less  of  this  caseous  material 
floats  in  the  fluid,  for  the  caseous  material  precipitates  to- 
wards the  wall  of  the  abscess  and  organizes  into  a  false  mem- 
brane of  varying  thickness  depending  upon  the  amount  of 
the  caseous  material  originally  present.  This  liquid  is  free 
from  mixed  infection  and  rarely  contains  the  tubercle  bacil- 
lus. It  practically  forms  a  healed  tubercular  area,  although 
the  individual  may  not  be  free  from  tuberculosis.  Any 
active  tubercular  process  in  the  same  individual  will  appear 
in  neighboring  glands  or  elsewhere,  but  the  cold  abscess- 
represents  a  healed  process. 
Treatment  Xhe  onlv  treatment  necessary  for  this  form  of  glands  is- 

consists  of 

puncture  or         puncture  or  aspiration. 

With  a  drop  or  two  of  one-fourth  of  one  per  cent,  of 
cocaine,  or  one-half  of  one  per  cent,  of  novocaine,  injected 
with  a  fine  hypodermic  needle  intracutaneously  over  the  part 


SURGICAL  TREATMENT  OF  TUBERCULAR  GLANDS        209 

of  the  gland  nearest  the  surface,  the  incision^  may  be  ren- 
dered painless.  The  incision  consists  of  nothing  more  than 
a  puncture  by  means  of  a  sharp  pointed  scalpel,  the  blade 
being  no  more  than  an  eighth  of  an  inch  wide.  If  the  liquid 
does  not  escape  through  this  incision,  a  circumstance  ex- 
tremely rare,  the  incision  may  be  widened,  or  a  little  sterile 
normal  saline  solution  injected  by  means  of  a  sterile  dropper 
will  render  the  contents  of  the  gland  sufficiently  fluid  to 
escape.  A  little  sterile  olive  oil  should  then  be  injected  to 
prevent  contact  between  the  opposite  walls  of  the  capsule 
and  a  small  cotton  collodium  dressing  applied. 


FIG.  49 


If  aspiration  is  resorted  to,  a  fairly  large-sized  needle 
should  be  used,  the  contents  aspirated,  and  before  with- 
drawing the  needle,  a  few  drops  of  sterile  olive  oil  shoulfl 
be  injected  into  the  sack. 

Frequently  the  needle  tract  will  remain  open,  causing 
a  narrow  fistula,  and  creating  the  same  condition  as  pro- 
duced by  puncture.  This  should  not  be  considered  detri- 
mental. On  the  contrary,  the  sack  may  be  re-emptied  of 
any  re-accumulation,  by  the  use  of  the  eye-end  of  a  needle 
or  even  with  a  toothpick  dipped  in  iodine,  pushed  into  this 
fistulous  tract.  With  an  ordinary  eye  dropper  a  few  drops 
of  sterile  olive  oil  should  be  injected  after  each  time  the 
sack  is  emptied,  in  order  to  prevent  the  rubbing  of  the  sur- 
face of  the  sack, — thus  preventing  re-accumulation  of 
secretions. 

Every  step  of  this  treatment  must  be  carried  out  under   strict  asepsis 
strict  asepsis.     By  the  use  of  iodine  on  the  skin,  the  aspi- 
rating needle  will  carry  no  infection  within ;  and  by  the  use 
of  a  little  collodium  dressing  or  alcohol  compress  over  the 
14 


210  TUBERCULIN  AND  VACCINE 

puncture,  subsequent  infection  of  the  cold  abscess  will  'be 
avoided.  , 

Both  puncture  and  aspiration  are  carried  out  mainly 
to  get  ahead  of  the  process  of  trjptic  digestion  which  is 
bound  to  set  in  when  a  cold  abscess  existed  for  any  length 
of  time.  Ugly  scarring  has  resulted  from  the  sloughing  of 
the  skin  over  cold  abscesses  through  the  process  of  tryptic 
digestion. 

Aspiration  If  we  succeed  in  getting  ahead  of  the  tryptic  ferment 

Seated  formation,    the   re-accumulation   of   secretions   will   become 

until  no  ]ogg  ant|  jeg      until  the  sack  becomes  contracted  upon  its 

reaccumulation 

takes  place.  more  solid  contents,  that  is,  the  caseous  false  membrane 
which  now  forms  the  only  contents  of  the  contracted  capsule. 
The  contents  may  be  slowly  forced  out  by  the  further  con- 
traction of  the  capsule  and  complete  healing  take  place;  or 
it  may  form  a  nodule  forced  out  upon  the  surface  of  the 
skin  which  heals  beneath.  The  nodule  dries  and  eventually 
falls  off  just  as  a  scab  does,  leaving  a  whitish  scar  beneath. 

Suppurating  Glands 

suppurating  Suppurating  glands  are  tubercular  glands   which  have 

glands  are 

local  pyogenic  become  infected  with  a  pyogenic  organism,  usually  the 
prolong^  by  staphylococcus.  Here  we  have  a  tubercular  process  ren- 
the  tubercular  dered  active  by  mixed  infection,  and  an  ordinary  abscess 

process.  .  *  7 

formation  continued  by  the  tubercular  process. 

Occasionally  the  removal  of  the  mixed  infection  will  be 
sufficient  to  cause  the  healing  of  the  tubercular  process  with- 
out any  other  treatment.  However,  in  most  cases  a  course 
of  tuberculin  will  do  away  with  the  tubercular  process  and 
will  suffice  to  bring  about  a  healing  by  removing  the  very 
clement  that  prevents  the  natural  termination  of  a  staphy- 
lococcus abscess.  It  is  advisable  to  resort  to  the  latter  means 
of  treatment  first  as  the  former  does  not  do  away  with  the 
tubercular  hypersusceptibility,  and  a  local  recurrence  or  a 
new  tubercular  infection  elsewhere  may  take  place. 

In  the  treatment  of  suppurating  tubercular  glands,  the 


SURGICAL  TREATMENT  OF  TUBERCULAR  GLANDS        211 
tuberculin   inoculation  may  suffice.     We  need  not  bother   Special 

'         f          i  •        i    •     p        •  1-1  •       treatment 

about  a  vaccine  lor  the  mixed  infection  until  it  becomes  evi-   is  not  often 
dent  that  the  mixed  infection  is  deep-seated  and  requires   neces! 
special  treatment  for  its  elimination. 

If  during  the  treatment  with  tuberculin  the  first  dilu- 
tion has  been  reached  without  having  produced  any  effect 
upon  the  local  process,  a  vaccine  treatment  for  the  mixed 
infection  should  be  undertaken. 


Cicatrized  Glands 

Cicatrized  glands  are  glands  enlarged  by  the  tubercular  cicatrized 
process  and  healed  by  the  formation  of  scar  tissue.  In  other  glands  that 
words,  healing  has  taken  place  by  fibrous  tissue  degeneration.  g"osls 

This  process  of  healing  of  tubercular  glands  unneces- 
sarily forms  a  discouraging  feature  in  tuberculin  treatment. 
To  the  patient  the  palpable  gland  means  the  persistence  of 
the  disease  and  occasionally  even  the  physician  may  not 
realize  that  fibrous  healing  jmay  take  place  in  glandular 
tuberculosis  as  in  lung  tuberculosis,  and  that  fibrous -healing 
in  glands  may  leave  them  palpable  or  even  as  large  as  they 
were  during  the  height  of  the  infection. 

I  therefore  call  particular  attention  to  this  form  of  heal-   special 

»      •,  i  i  -.  treatment  is 

ing  oi  the  tubercular  process;  so  that  we  may  not  under-  almost  always 
rate  the  tuberculin   treatment  when   this  form   of  healing   necessary- 
occur?  in  a  case  of  tubercular  glands.     For  here,  just  as  in 
bone  and  joint  tuberculosis,  we  cannot  expect  tuberculin  to 
eliminate   the  results   of  fthe  tubercular  infection  while  it 
eradicates  the  infection  itself.  . 

After  the  disease  has  been  converted  into  a  purely  local 
process  by  means  of  immunotherapy,  the  following  methods 
of  treating  the  local  condition  may  be  resorted  to: 

First,  we  may  inject  substances  within  the  glandular 
stroma  in  order  to  soften  the  fibrous  tissue,  by  producing  a 
destructive  or  cauterizing  process. 

Second,  we  may  remove  what  remains  of  the  glands 
through  surgical  interference. 


212  TUBERCULIN  AND  VACCLNE 

softening  of  Sof  tening  of  the  hard  cicatrized  glands  may  be  brought 

mass^y1"  about  by  the  injecting  of  iodine  or  synthetic  guaiacol  into 

means  of  ^  center  of  the  gland ;  or  even  a  drop  or  two  of  carbolic 

chemicals.  .      '  . 

may  be  injected  through  a  hypodermic  needle,  using  alcohol 
on  the  surface  of  the  skin  to  prevent  burning.  After  two  or 
three  injections,  about  a  week  or  two  apart,  the  gland  will 
begin  to  soften  and  may  be  treated  as  a  soft  gland.  The 
following  formula  will  be  found  useful  for  this  purpose: 

I£     Synthetic  guaiacol  Merck,  gm.  6 

Metallic  iodin,  "  3 

Sodium  iodid,  "  6 

Glycerin,  "  30 

Saccharin,  "  0.50 

Distilled  water,  "  10 
Misce  et  solve. 

Conservative  When  resorting  to  surgical  measures  in  the  treatment  of 

cicatrized  glands,  radicalism  is  unnecessary.  Tuberculin 
has  eliminated  radical  surgery  in  tubercular  processes,  par- 
ticularly in  tubercular  glands;  and  once  hypersusceptibility 
has  been  removed,  new  tubercular  processes  need  not  be 
feared.  Under  local  anesthesia  and  through  the  smallest 
possible  incision,  the  gland  can  be  easily  separated  from  its 
surrounding  tissue  by  blunt  dissection  or  scissors.  The  inci- 
sion may  be  closed  by  subcuticular  suture. 

Where  there  are  several  enlarged  glands,  it  is  best  to 
make  a  separate  incision  for  each,  instead  of  using  one  large 
incision  for  the  removal  of  all  the  glands.  A  large  gland 
may  be  removed  by  morselation  through  a  small  incision. 


CHAPTER  VIII 
BONE  CAVITIES,  SIN-USES  AND  FISTULAS 

Infection  of  bone  is  synonymous  with  chronicity.  The  Bone  infection 
nature  of  bone  tissue  precludes  hyperemia  from  the  point  with"h°oTicity 
of  infection;  hence,  the  insufficient  immune  response  during 
the  infection,  and  the  retarding  of  anabolism  through  insuf- 
ficient blood  supply  during  healing.  Again,  while  in  the 
case  of  soft  tissue  the  destroyed  tissues  escape  in  the  form 
of  pus,  in  the  lease  of  bone,  the  products  of  infection  remain 
solid,  forming  sequestra  which  make  the  escape  of  destroyed 
tissue  difficult  or  impossible.  We  are  here  dealing  with  a 
foreign  body,  which  in  addition  to  the  infection  contributes 
materially  to  the  chronicity  of  the  process. 

Even  without  the  formation  of  sequestra,  the  healing  of  The  formation 
bone  tissue  and  the  formation  of  new  bone  is  so  slow  that  and  sinuses. 
wound  discharge  takes  place  for  a  considerably  longer  time 
than  in  soft  tissue.     The  route  through  which  these  products 
of   infection    are    discharged    must   remain    open    for    long 
periods  of  time.     Assuming  a  similar  function  to  that  which 
natural  canals  possess  for  the  discharge  of  excretion,  these 
passages  become  lined  with  a  granulation  tissue  layer,  which 
is  protective  by  preventing  the  closure  of  these  channels. 
The  result  is  the  formation  of  'fistulas  and  sinuses. 

The  treatment  of  tubercular  bone  and  joint  disease  must  A  combined 
embrace  besides  the  eradication  of  the  tubercular  infection,   essential, 
which  was  discussed  in  Part  II,  the  elimination  of  mixed 
infection  and  the  restoration  to  as  nearly  normal  a  condition 
as   possible  the   structural   changes  that   have  taken   place 
as  a  result  of  the  tubercular  infection. 

Mixed  Infection 

Mixed  infection  in  cases  of  tubercular  bone  disease  dif- 
fers in  but  few  respects  from  mixed  infection  in  other  tuber- 


214  TUBERCULIN  AND  VACCINE 

The  utilization     Cular  infectious.     The  difference  can  best  be  understood  if 

of  the  immune  •  _      _         ..  ...         ,,        , 

response  is          we  bear  in  mind  that  we  have  to  deal  with  an  inferior  blood 

^udToT1  b          supply  when  the  immune  response  is  utilized  in  treatment  of 

hyperemia.          fane  infections.     Once  we  have  this  fact  established,  we  are 

ready  to  employ  infinite  patience  in  the  treatment  of  bone 

disease. 

What  is  more,  there  is  nothing  to  impede  our  progress 
once  we  start,  for  this  class  of  patients  will  permit  all  the 
time  and  experimentation  that  a  course  of  treatment  re- 
quires. All  they  wish  in  return  is  a  reasonable  hope  for  an 
eventual  cure.  For  of  all  tubercular  cases  these  are  the 
most  pitiable.  Although  their  lives  are  not  threatened,  and 
although  in  most  other  respects  they  are  physically  well, 
still  their  condition  stands  between  them  and  self-support, — 
often  between  them  and  self-respect.  For  the  tender  care 
and  sympathy  extended  to  the  sick  spends  itself  in  time, 
leaving  these  patients  to  the  monotonous  routine  of  daily 
dressing  their  wounds  and  obtaining  their  livelihood  as  best 
they  can.  In  any  case  they  are  a  burden  to  their  families, 
and  often  to  the  community.  This  is  the  hopeless  condition 
in  which  these  sufferers  approach  us.  So  that  it  is  no  won- 
der that  any  hope  of  cure  will  be  welcomed,  no  matter  how 
much  time  or  experimentation  it  involves.  That  is  why  the 
element  of  time  does  not  have  to  be  seriously  considered  in 
a  course  of  treatment  such  as  bone  tuberculosis  requires. 

Treatment.  After  the  tuberculin  treatment  has  been 
applied  for  a  week  or  two,  it  is  advisable  to  begin  the  treat- 
ment for  the  mixed  infection,  proceeding  as  follows:  A 
smear  of  the  pus  is  made,  and  stained  with  methylene  blue 
for  the  diagnosis  of  the  organism  causing  the  mixed  infec- 
tion. If  no  bacteria  are  found,  a  further  test  as  to  the 
sterility  of  the  discharge  should  be  made  by  inoculating  a 
culture  tube  of  serum  agar.  If  no  growth  appears  in  forty- 
eight  hours,  the  pus  discharge  is  due  to  the  tubercular  pro- 
cess alone,  and  no  further  attempt  to  influence  the  local 
condition  by  means  of  vaccine  need  be  made.  The  tuber- 


BONE  CAVITIES,  SINUSES  AND  FISTULAS  215 

culin  treatment  for  the  systemic  condition,  and  bismuth 
paste  for  the  local  condition  will  suffice.  If,  however,  the 
smear  or  the  culture  tube,  or  both,  revealed  the  presence  of 
mixed  infection,  we  proceed  to  treat  the  patient  with  a  stock 
vaccine  after  a  diagnosis  of  the  causative  organisms  is  made. 
(See  Chapter  IV.) 

The  mixed  infections  occurring  in  tuberculosis  of  bones   Mixed 
and  joints  are  the  simplest  forms  of  infections  for  vaccine   in  bone  and 
treatment.     The  causative  organisms  in  the  largest  majority   'omt  dlsease 
of  cases  are  the  staphylococcus,  albus  or  aureus.     The  strep-   simplest  forms. 
tococcus  comes  next  in  order  of  frequency,  occasionally  the 
pneumococcus  makes  its   appearance,   and  very  rarely  the 
colon.    Thus  it  will  be  seen  that  the  most  easily  distinguished 
bacteria,  both  in  smear  and  culture,  —  the  staphylococcus  and 
the  streptococcus  —  are  responsible  for  most  cases  of  mixed 
infection,  in  bone  and  joint  tuberculosis. 

A  stock  vaccine  of  one  of  the  organisms  found  in  the  pus   Stock  vaccines 
should  be  tried  for  a  few  weeks,  the  dosage  being  the  same  maybe 

7  employed. 

as  for  chronic  mixed  infections  (Chapter  IV).     And  if  no  Autogenous 
effect  is  produced  such  as  a  change  in  consistency  or  in  the  gh 


quantity  of  the  discharge,  a  stock  vaccine  of  one  of  the  other  resorted  to 

~  '  .  when  stock 

organisms  should  be  tried  for  as  long  a  time  as  the  first  It  vaccine  has 
may  be  necessary  at  times  to  obtain  an  autogenous  vaccine 
to  produce  the  desired  effect.  Especially  is  this  true  in  the 
case  of  the  streptococcus,  where  the  strains  are  so  numerous 
that  the  strain  causing  the  infection  may  have  been  over- 
looked in  the  manufacture  of  the  polyvalent  stock  vaccine. 

As  I  have  previously  stated,  it  is  better  to  use  a  vaccine   vaccines 
of  one  organism  at  a  time  in  case  of  multiple  infection,  than   ^"^^"j 
to  use  vaccines  for  all  of  the  organisms  at  the  same  time. 
Xot  that  there  is  any  serious  objection  to  the  latter  method, 
but  since  the  tuberculin  treatment  must  necessarily  last  a 
length    of    time    which   offers    ample    opportunity    for    the 
former  or  slower  method  of  vaccine  treatment,  it  should  be 
adopted  as  it  has  distinct  advantages.     Thus  it  will  often 
be  found  that  when  using  a  vaccine  against  one  of  the  bac- 


216  TUBERCULIN  AND  VACCINE 

teria  in  a  multiple  infection,  the  other  bacteria  will  dis- 
appear spontaneously,  making  it  at  once  evident  that  they 
were  simply  parasitic  forms  and  took  no  part  in  the  mixed 
infection. 

On  the  other  hand,  it  may  happen  that  after  the  use  of 
a  vaccine  against  one  of  the  organisms,  another  may  so 
increase  in  number  as  shown  in  a  subsequent  stained  smear, 
that  it  leaves  little  doubt  as  to  its  participation  in  the  infec- 
tion. A  vaccine  for  this  organism  should  be  at  once  em- 
ployed. All  these  variations  will  become  evident  only  if 
the  vaccine  therapy  is  applied  ini  a  spirit  of  scientific  inter- 
est— the  empirical  use  of  vaccines  will  not  only  fail  in  a 
great  many  cases,  but  even  when  successful,  will  add  noth- 
ing to  the  physician's  experience  which  can  be  utilized  in 
subsequent  cases. 


CHAPTER  IX 
BISMUTH  PASTE 

Having  considered  the  treatment  of  the  etiological  infec-   Bismuth 
tion  and  the  treatment  of  the  mixed  infection  of  tubercular  prominent 
cavities  and  sinuses,  we  must  now  turn  our  attention  to  the  element  m  the 
reconstruction  of  tissues  in  order  to  remove  the  mechanism,    TREATMENT. 
which  though  it  was  established  as  part  of  the  defensive  pro- 
cesses of  the  individual,  was  so  well  established  that  the  body 
cannot  rid  itself  of  it  spontaneously  once  the  reason  for  its 
existence  has  passed. 

A  better  understanding  of  the  mode  of  action  of  bismuth  Formation  of 
paste  will  be  obtained  if  we  have  clearly  before  us  the  channels, 
mechanism  by  which  pathological  cavities  and  sinuses  form 
and  continue  their  existence.  In  the  first  place  nature 
builds  a  wall  around  a  chronic  infection  as  part  of  its  pro- 
tective mechanism.  The  products  of  the  chronic  infection 
must  escape — hence  the  formation  of  sinuses  and  fistulas. 
Once  the  process  is  chronic,  the  necessity  for  the  existence 
of  the  fistulous  tracts  will  remain  for  a  considerable  length 
of  time.  Mature,  therefore,  lines  these  tracts  in  the  same 
manner  as  she  lines  natural  passages — with  a  secreting  mem- 
brane. ^Yhat  was  originally  meant  as  protective  construc- 
tion, thus  becomes  the  means  of  the  prolongation  of  the 
pathological  process.  These  cavities  and  sinuses  are  con- 
stantly filled  with  a  sero-purulent  irritating  accumulation, 
aiding  materially  in  prolonging  their  existence.  The  sero- 
purulent  accumulation  is  brought  about  by  the  negative 
osmotic  pressure,  causing  a  flow  of  lymph  and  serum  toward 
the  empty  space  forming  the  cavity.  This  offers  an  admir- 
able situation  for  mixed  infections.  The  serous  accumula- 
tion forms  the  best  cultural  media  for  bacterial  growth — the 
proper  temperature  is  always  present,  and  the  bacteria  are 
at  the  same  time  beyond  the  reach  of  the  antibodies. 


218  TUBERCULIN  AXD  VACCINE 

Action  of  When  such  a  cavity  is  filled  with  bismuth  paste  the  fol- 

bismuth  paste.  •, 

lowing  results  are  produced: 

First,  the  bismuth  paste  possessing  a  specific  gravity  far 
in  excess  of  the  surrounding  tissues,  practically  stops  the 
irritating  accumulations. 

Second,  mechanical  pressure  exerted  'by  the  bismuth 
paste  upon  the  lining  cells  causes  atrophy  of  these  cells — 
thus  removing  one  of  the  principal  causes  that  prevent 
healing. 

Third,  bismuth  acting  as  a  foreign  ,body  stimulates  the 
contraction  of  the  tissues  upon  it  so  that  the  cavities  hold 
less  and  less  bismuth  with  each  subsequent  injection  until 
final  obliteration  of  the  cavity  takes  place. 

Fourth,  according  to  Beck,  bismuth  possesses  a  kymo- 
techtic  property  aiding  in  the  production  of  hyperemia — 
the  element  that  is  most  needed  in  overcoming  chronic 
disease. 

Fifth,  bismuth  paste  possesses  the  quality  of  retaining 
to  some  degree  radio-active  properties,  which  are  imparted 
to  it  by  the  X-rays.  Frequent  Roentgenographic  examina- 
tions while  the  tubercular  tract  is  filled  with  bismuth  paste 
will  facilitate  the  cure  of  these  conditions. 

Composition  of  Bismuth  Paste 

Bismuth  paste  consists  of  bismuth  and  vaseline.  Hard 
paraffin  and  white  wax  is  added  when,  owing  to  a  large  fis- 
tulous  opening,  it  is  difficult  to  retain,  and  a  more  solid  con- 
sistency is  required.  The  usual  proportions  are  one-third 
bismuth,  two-thirds  vaseline.  "When  five,  ten  or  fifteen  per 
cent,  hard  paraffin,  together  with  five  per  cent,  white  wax 
are  added,  the  bismuth  content  may  be  reduced  to  thirty  per 
cent.,  and  the  vaseline  quantum  sufficit.  The  bismuth  may 
be  further  reduced  to  twenty,  ten  or  even  five  per  cent., 
when  the  injection  is  made  into  a  great  depth,  and  where 
its  removal  may  prove  difficult,  also  where  the  cavity  is  of 
such  size  that  the  total  quantity  of  bismuth  paste  injected 


BISMUTH  PASTE  219 

is  large.  I  have  seen  lanolin  used  instead  of  vaseline.  That 
is  distinctly  contraindicated,  as  lanolin  is  an  absorbable  base 
and  would  encourage  the  absorption  of  bismuth  along  with 
it.  The  use  of  lanolin  as  a  base  is  probably  responsible  for 
the  fear  that  bismuth  paste  may  cause  bismuth  poisoning. 
In  ten  years  of  experience  with  bismuth  paste,  I  have  seen 
but  one  case  where  there  seemed  to  be  a  tendency  to  bismuth 
poisoning,  and  that  occurred  in  the  case  of  pulmonary 
abscess,  where  fourteen  fluid  ounces  of  the  paste  had  been 
injected  in  a  patient  for  diagnostic  X-ray  examination.  It 
was  afterward  discovered  that  this  patient  possessed  a  spe- 
cial idiosyncrasy  for  bismuth — the  poisonous  symptoms  ap- 
pearing after  the  injection  of  a  very  small  quantity.  Aside 
from  this  case,  there  never  occurred  the  slightest  suggestion 
of  bismuth  poisoning  in  the  hundreds  of  cases  that  have  come 
under  my  personal  experience. 

Bismuth  Paste  Formulas  variations 

T  IT     TTT      TV  inthe 

bismuth  paste 

Bismuth  Subnitrate 33  1-3       10       20       30   formula. 

Paraffin  (120  melting  point)  ....  5 

White  Wax 5 

Vaseline.  .  66  2-3       90       80       60 


100  100     100     100 

With  regard  to  the  therapeutic  application  of  bismuth 
paste,  the  following  are  the  most  important  points  requiring 
attention : 

The  bismuth  paste  must  be  absolutely  smooth,  as  solid   careand 
particles  of  bismuth  may  become  separated  from  the  vaseline  fo'hlJecti 
and  form  a  concretion.     Only  such  quantity  of  the  paste 
should  be  sterilized  as  is  required  for  immediate  use,  for 
the  frequent  heating  of  the  bismuth  paste  spoils  the  con- 
sistency of  the  vaseline  and  allows  the  precipitation  of  the 
bismuth.     The  sterilization  of  the  bismuth  paste  for  imme- 
diate use  is  accomplished:  (1)  by  boiling  a  receptacle  large 


220  TUBERCULIN  AND  VACCINE 

enough  to  contain  the  quantity  of  bismuth  paste  required, 
together  with  the  syringe;  (2)  jby  putting  the  required 
amount  of  bismuth  paste  in  the  sterile  receptacle  which  is 
then  placed  in  boiling  water.  The  flame  under  the  boiling 
water  is  turned  out,  ,and  the  bismuth  allowed  to  stand  in  the 
hot  water  for  ten  minutes.  This  permits  of  a  pasteurization 
of  the  bismuth  paste,  the  cooling  of  the  water  during  the  ten 
minutes  not  going  below  the  pasteurization  point  It  is  not 
necessary  to  boil  bismuth  paste  to  obtain  sterility,  as  both 
bismuth  and  vaseline  inhibit  the  growth  of  bacteria,  hence 
pasteurization  is  sufficient  to  kill  any  bacteria  that  get  in 
during  the  manufacture  of  bismuth  paste. 

The  more  fluid  the  paste,  while  being  injected,  the  more 
certain  it  is  to  completely  fill  all  the  sinuses  and  cavities. 
However,  care  must  be  taken  not  to  allow  the  paste  to  be  hot 
enough  to  cause  pain  to  the  patient. 

Bismuth  Injections 

The  proper  syringe  is  a  plain  glass  syringe  with  an  asbes- 
tos packing,  the  syringe  varying  in  size  from  two  drams  to 
four  ounces.  It  is  best  to  have  the  tip  blunt  and  rounded, 
as  per  illustration  (Fig.  55),  rather  than  a  catheter  end 
which  would  go  into  the  fistula.  I  prefer  to  avoid  putting 
into  a  fistulous'  tract  any  hard  instrument  which  might  cause 
injury  and  bleeding.  The  blunt  point  placed  against  the 
fistula's  opening  with  gentle  pressure  will  answer  the  pur- 
pose every  time.  Inject  the  bismuth  slowly,  using  steady 
but  gentle  pressure  until  the  patient  feels  discomfort  from 
distension,  or  until  the  resistance  causes  an  overflow  of  the 
paste  around  the  tip  of  the. syringe,  or  until  the  bismuth 
shows  through  the  other  fistula  or  fistulas. 

If  more  than  two  fistulas  exist  a  gentle  pressure  is  applied 
on  the  mouth  of  the  fistula  where  the  bismuth  first  makes 
its  appearance,  and  the  injection  of  the  bismuth  is  continued 
until  it  begins  to  show  at  the  mouth  of  the  next  fistula.  The 
same  pressure  should  be  applied  to  the  third  fistulous  open- 


BISMUTH  PASTE  221 

ing  if  a  fourth  exists.  This  procedure  is  continued  until 
the  bismuth  appears  from  all  the  fistulous  openings.  Only 
then  are  we  certain  that  if  a  cavity  exists,  it  is  filled  with 
bismuth,  and  that  all  the  accumulations  in  that  cavity  have 
been  removed  ahead  of  the  advancing  bismuth  column. 

If   fistulas   exist   which   do   not   communicate,   bismuth 
should  be  injected  into  each  separately. 

Bismuth  Paste  Retention.     Although  bismuth  paste  is   varying 
of  value  in  removing  the  infective  and  irritative  accumula-   CQ°  b 


tions  from  fistulas  and  cavities,  it  cannot  prevent  reaccumu-   paste  for 

T  .  .  .    .  ,  .       retention. 

lations  nor  stimulate  contraction  01  the  cavities  unless  it 
remains  there  for  at  least  twenty-four  hours,  preferably 
forty-eight  hours  at  a  time.  It  is,  therefore,  necessary  to 
prevent  the  immediate  outflow  of  the  bismuth  paste  after 
injection.  That  can  be  done  in  the  first  place  by  varying  the 
consistency  of  the  bismuth  paste  according  to  the  size  of  tie 
fistulous  opening.  For  instance,  a  large  opening  must  have 
thicker  bismuth  paste,  whereas  for  a  very  small  one  a  more 
fluid  bismuth  paste  can  be  employed.  In  the  second  place, 
the  consistency  of  the  bismuth  paste  should  depend  upon  the 
depth  and  the  distance  of  the  cavity  from  the  surface.  A 
cavity  will  retain  bismuth  paste  of  a  lighter  consistency  for 
a  sufficient  length  of  time  if  the  outlet  to  the  surface  is 
formed  by  a  tortuous  and  long  fistulous  tract.  Whereas  a 
channel  that  is  near  the  surface  and  has  a  short  outlet  will 
have  to  be  filled  with  a  bismuth  paste  that  remains  quite 
'hard  at  body  temperature.  The  consistency  of  the  bismuth 
paste  can  be  varied  by  the  addition  of  five  or  ten  per  cent. 
hard  paraffin  (see  formulas,  page  219). 

The  fistulas  can  be  sealed  with  cotton  collodium  or  plugs 
of  cotton  or  gauze,  retained  by  adhesive  plaster.  Small 
tampons  may  be  used,  pushed  into  the  channel  and  prevented 
from  falling  beyond  reach  by  an  attached  string  which  is 
tied  over  an  adhesive  strip  going  across  the  opening;  or  a 
string  attached  to  a  piece  of  adhesive  plaster  may  be  placed 
at  opposite  sides  of  the  fistula  and  at  some  distance  from  it. 


222  TUBEKCULIX    AND    \7ACCIXE 

By  tying  these  strings  together,  the  adhesive  plasters  are 
drawn  together,  pulling  the  skin  with  them,  thus  closing  the 
fistula. 

intervals  Frequency  of  Treatment.     :The  best  interval  between 

inactions,  and  injections  is  forty-eight  hours.  If  the  bismuth  is  well  re- 
instruction  to  tamed,  the  intervals  may  be  longer.  However,  the  interval 

patients  as  to  i  i  -r      •      i 

the  care  of  should  not  be  longer  than  a  week.  It  is  best  to  renew  the 
during""/8  bismuth  paste  in  the  (diseased  area  at  least  once  a  week  for 
intervals.  two  reasons :  (1)  to  prevent  the  formation  of  concretions; 

(2)  to  avoid  unfavorable  results  that  may  occur  in  a  fistu- 
lous  branch  which  may  not  have  been  filled  by  the  bismuth, 
and  which  retains  its  irritating  and  infective  contents  as  a 
result  of  the  blocking  of  the  exit  by  the  bismuth.  In  case 
redressing  of  the  fistulous  opening  by  the  patient  becomes 
necessary  during  the  interval,  the  patient  is  instructed  al- 
ways to  use  gauze  or  cotton  saturated  in  alcohol,  to  avoid 
the  constant  danger  of  reinfection. 

Where  there  is  only  one  fistulous  opening,  making  it 
therefore  impossible  to  remove  the  old  bismuth  ahead  of  the 
advancing  column  of  the  fresh  bismuth,  and  where  the  bis- 
muth does  not  spontaneously  ooze  out  during  the  interval, 
we  follow  the  advice  of  Beck  by  using  injections  of  sterile 
olive  oil  to  soften  and  wash  out  the  bismuth  just  previous 
to  the  injection  of  the  fresh  paste. 

The  Proper  Direction  of  Bismuth  Paste 

A  closer  study  of  a  number  of  cases  of  open  bone  disease 
that  resisted  the  combined  treatment,  has  yielded  a  more 
intimate  understanding-  of  the  mechanism  which  continues 

present  to 

allow  of  the         the  existence  of  cavities,  sinuses  and  fistulas.   Aside  from  the 

escape  of  the  -11    -i  ,.  ,  -    ,,         ,  - 

purulent  weli  known  purpose  lor  the  existence  of  fistulas  and  sinuses 

—drainage, — the  study  revealed  the  importance  of  a  proper 
direction  for  such  drainage  in  relation  to  bismuth  paste 
injection.  This  finding  at  once  explained  that  the  former 
resistance  to  treatment  in  many  cases  was  due  to  a  faulty 
direction  of  the  flow  of  the  bismuth  paste.  No  sooner  was 


BISMUTH  PASTE  223 

this  direction  altered  in  such  a  way  as  to  conform,  with  the 
principles  of  bismuth  paste  injections,  than  conditions  which 
resisted  treatment  for  a  number  of  years  promptly  began  to 
improve  and  soon  healed. 

In  the  process  of  formation  of  fistulous  tracts  the  area 
through  which  the  inflammatory  products  have  to  traverse 
in  order  to  reach  the  surface  may  be  composed  of  such  tis- 
sues that  in  taking  the  direction  of  least  resistance,  the  course 
becomes  zigzag  and  tortuous.  For  instance,  when  heavy 
fascial  layers  interpose  between  the  point  of  bone  infection 
and  the  surface  of  the  body,  the  direction  of  drainage  may 
be  deflected  by  this  fascia  for  a  varying  distance,  allowing  it 
to  come  to  the  surface  where  the  fascial  layer  either  thins  or 
disappears.  The  fistulous  opening,  therefore,  will  appear 
at  a  point  removed  from  the  point  of  bone  infection — in  fact, 
at  times  the  distance  is  so  great  that  only  special  investiga- 
tion will  discover  the  relation  between  that  fistulous  opening 
and  a  given  bone  infection. 

In  other  cases  the  suppurative  process  takes  two  or  more 
directions  before  reaching  the  surface.  But  not  all  such  fistu- 
lous tracts  need  reach  the  surface.  For,  as  soon  as  one  or 
two  of  the  tracts  do  reach  the  surface,  the  pressure  is  relieved 
and  the  process  in  the  rest  of  the  sinuses  discontinues.  The 
result  is  the  formation  of  blind  fistulas  or  pouches. 

It  is  difficult  to  fill  completely  blind  fistulas  and  pouches   counter 
which  are  really,  cavities,  having  only  one  opening  at  some  ^puesnt'"ftsen  be 
distance  from  the  cavity  itself.    Where  several  counter  opeti-   established 

!         i  .    i       i       i  •  i  .      .         -•  surgically. 

mgs  exist  through  which  the  bismuth  can  escape,  it  is  almost 
impossible  to  fill  such  blind  fistulous  pouches.  The  advanc- 
ing bismuth  column  turn?  the  corner  and  leaves  through  a 
neighboring  sinus,  and  thus  not  only  fails  to  completely  fill, 
but  even  bottles  up  the  discharge  in  the  blind  fistula  or 
pouch.  This  circumstance  is  responsible  for  the  sudden 
pointing  of  a  new  abscess  and  the  formation  of  an  added 
fistula  during  treatment.  For  the  moment  such  an  occur- 
rence is  discouraging  and  is  looked  upon  as  evidence  of  fail- 


224  TUBERCULIN  AND  VACCINE 

nre,  a  ml  frequently  leads  to  the  discontinuance  of  the  treat- 
ment. In  truth  nature  has  accomplished  something  which 
the  physician  should  have  done  long  before — established  the 
proper  direction  for  the  passage  of  the  bismuth  paste.  A 
reference  to  the  diagram  (Fig.  50)  will  render  this  subject 
clearer. 

Roentgenography     < 

without  the  The   direction   of   the  bismuth  paste  cannot  be  deter- 

mined without  one  or  two  X-ray  examinations  made  dur- 

X-ray  photo-  •> 

graph  the  ing  treatment,  and  so  some  mention  of  the  utility  of  Roent- 

counter-  gcnography    in    this    connection    should    be    made.      It    is 

almost  impossible  to  gain  any  knowledge  of  the  various 
discovered.  channels  or  cavities — whether  as  to  size  or  direction — with- 
out an  X-ray  photograph  of  the  entire  part  involved  com- 
pletely filled  with  bismuth  paste.  Probing  is  to  be  con- 
demned even  if  it  were  to  enable  the  determination  of  any- 
thing of  diagnostic  value.  A  glance  at  Fig.  51  will  show 
how  hopeless  the  probing  would  be  in  such  a  network  of 
channels. 

The  stereo  The  stereoscopic  radiograph  is  the  latest  development  of 

X-ray  study.  By  taking  two  exposures  of  the  same  part  on 
separate  plates,  each  exposure  from  a  different  angle  and 
the  difference  gauged  to  correspond  to  the  difference  in  the 
angles  between  the  human  eyes,  a  stereopticon  picture  is 
produced  which  when  viewed  through  a  stereoscope  shows  the 
part  in  three  dimensions.  The  exact  relations  of  the  various 
tubercular  channels  and  cavities  to  the  tissues  are  seen, 
which  render  the  application  of  the  various  surgical  meas- 
ures far  more  easy.  If  possible,  a  stereo-radiograph  should 
be  insisted  on. 

Therapeutic  The  X-ray  has  another  important  application  in  relation 

applications.  to  bismuth  paste — that  is  a  therapeutic  application.  It  was 
noticed  that  those  cases  that  were  exposed  to  the  X-rays 
after  bismuth  injection  for  diagnostic  purposes  healed  more 
rapidly  than  those  cases  that  were  treated  with  bismuth 
paste  but  never  had  an  X-ray  photograph  taken.  This  led 


%>->  In 

v  l:lfMl  i 


EXPLANATION  OF  FIG.  50 

When  bismuth  paste  is  injected  at  F2  it  will  go  in  the  direction  of 
least  resistance  and  escape  at  Fl.  If  Fl  be  closed  by  a  dressing  sufficient 
to  prevent  the  escape  of  the  bismuth,  the  paste  will  then  rise  until  it 
reaches  b,  where  the  branch  sinus  d  is  given  off.  Then  instead  of 
rising  to  fill  the  blind  sinus  a,  and  the  cavity  c,  it  takes  the  direction 
down  through  d  because  that  is  the  direction  of  least  resistance  com- 
municating as  d  does  with  the  surface  through  the  fistulous  openings 
F3,  F4,  F5,  F6,  F7,  and  F8.  Whereas,  in  attempting  to  fill  a  and  c, 
the  paste  would  have  to  replace  an  amount  of  discharge  which  has  no 
outlet  once  the  point  b  is  filled.  In  this  case,  a  puncture  incision,  after 
a  little  cocaine  infiltration,  at  X  which  was  nearest  the  surface,  removed 
the  only  barrier  to  a  cure.  Subsequent  bismuth  injections  were  given 
through  this  puncture  at  X,  which  permitted  of  an  easy  filling,  of  the 
entire  system  of  fistulas  and  cavities. 


V  '•' 

V 


4i»b«tl  something 
:  Irefore — 
the  bi.srauth 
will  rend-  .  abject 


1  «ntgenography 


Witt 

aido  >  X-ray  examination-:  inr- 

grapi 

u>.n    ;,hould    be    made.      It 

coun 

open  oa  .oil  10  KpiTAKAj'ijcS    (>f   the  various 

cann 

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jfMi'-u'fhjs  jjfiiae;>-ib  a  '{d  Leeolo  9<f  T>I  H  Jpl.ta 
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x-ra  fiovomaj  (9-jj;lii/-?  3ffd  JgsiKsn  e.Gvr  ri-ji/Iw  X  ds  .noideidlSai  aniBOOO  sIWH  c 

novrs  9-iov/  snoijoo[tii  if  It/maid  dnaupggduS     .91110  «  oJ  igin^d  ^Ino  9di 
oifj  1o  •aniffft  ^»BO  an  lo  b9itiirn9q  dohfw  ,X  djs  gTWioniirj  girfj 

b«B 


]••  ti  con  picture  is 

-rt<»scope  shows  the 

iuti-  of  the  various 

tissues   are   s-ceu, 

.s  surer  Jcal  ineas- 


Thei 
X-ra 

appl 

o.!----.jfd  [•»  the  X-rays 
•Jiai  :)«>='••'  p.-rpr^^  healed  more 
;;.d-  n**-}-*  <.".-->i»-d  ^Ith  bi?rrmth 

Thi*  Ir-d 


FIG.  50 


FIG.    51 

FIG.  51  is  a  radiograph  of  the  same  condition  illustrated  by  the 
schematic  drawing,  Fig.  50.  This  young  man,  twenty-two  years  of 
age,  had  tubercular  hip  joint  disease  which  during  a  period  of  five 
years  totally  destroyed  the  hip  joint.  The  network  of  channels  had 
eight  fistulous  openings  which,  in  spite  of  all  the  modern  methods  of 
treatment,  continued  to  discharge  through  the  five  years,  and  required 
from  two  to  four  dressings  a  day.  A  course  of  tuberculin  and  vaccine 
treatment  for  the  mixed  infection  and  bismuth  paste  injections  pro- 
duced a  gain  in  weight  ,and  strength,  and  reduced  the  discharge  so 
that  only  one  dressing  a  day  was  required.  But  beyond  this  improve- 
ment, the  condition  resisted  treatment  for  many  months  until  this 
radiograph  was  made  immediately  after  the  careful  injection  of  bis- 
muth with  all  the  fistulas  sealed  except  one  at  6,  and  an  amount  in- 
jected until  the  patient  felt  distressed.  (( See  Fig.  52  of  the  same  patient 
taken  four  months  later.) 


15    .r 


arfi   ^d   bsiirrtaudi  noiiiLuoa  gm^e  ariJ  io   dqfiigoifuri  B  ai  13  .oil 
lo   siB9-£   owi-^JrrewJ   ,niifn   gnuo^   aiifT      .05    .yi'i    ,£fiiv/Bib   9iJj;raoiI-j3 
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i»:j|   alsHnnrfa   Jo  jliov/ion  srfT     .daioL  qii(   orft  bs^oiJaeb  y[[r,t-»j 
lo  «L<M[ififrr  meborri  9(f-t  llu  io  oJiq*  ni  ,rioi/Iw  egninaqo  euolii^r.n  .tilyio 
i  LIIB  ,MB9^  svft  oifi  (fyuo'itfi  s^ijjffoeil*  oi  LsiiniJnoo  ,Jn9nrtf;'jiJ 
hire  niluoindiii  lo  9211/00  A     .^ub  js  ^yni^gaifa   iuol  o^  owd  moil 
rfjomsicf  ban   noijoo^ni   f)9zim  9ffJ   10! 
Ln/:,  irfgiow   ni   nifi 

i  »iifi  bnoygd  Jjjfl     .bsiiupsi  anw  -^b  &  ^niaasib  9«o  ^In 
ftiiU    Jihm    8iBnom   ^num   lot   in<;f(j*B')iJ   bsixii-yi    nobibnoo   srfi   ftnoni 
-rid  lo  noii99[fli   Ii/l9ifto  9ifJ  i9Jbi   ^IsiBibsuimi   abKtrr  8j; 
-ai  ^nirouifi  HB  b«s  ,6  is  sno  iqgoics  bsl/ssd  efilui^il  etfl  HB  diiv/ 
iniiteq  'juiue  adj  lo  S5  .^il  998)     .busestieib  Jlsl  daoiicq  9(fi  liinu 

erfJaora  ii/ol 


d 


FIG.  51. — DIRECTION  OF  BISMUTH  PASTE. 


FIG.    52 

FIG.  52  is  a  radiograph  of  the  same  patient  as  Fig.  51  four  months 
later.  The  entire  condition  is  healed  except  for  the  fistulous  opening 
at  6,  which  admitted  a  few  drops  of  bismuth  paste.  Traces  of  bis- 
muth may  still  be  seen  in  the  tissues  around  the  hip  joint  and  on  the 
inner  side  of  the  leg  below.  : 

It  is  nearly  a  year  since  this  radiograph  was  made  and  no  recur- 
rence has  taken  place.  The  patient  is  now  employed  and  self-supporting. 


S2    .oil 

adiiiorn  ii/ot  1C  .§11  Be  Jflsijisq  smee  adi  io  dqKT§oi[»Bi  c  ai  1:5  .-''il 
i2(rincHfo  rtioIij^Ki)  adi  10!  dqaoxs  bolissA  ai  noiitbnoo  9'iihro  9iIT     .isJul 
>id  io  f-ooBiT     .steaq   diomeid  lo  feqoib   wal   c  feiJirrifj/;   d-jidv. 
•jd>  no  Imp,  jnioj;  qid  sdi  hn0oiB  eai/BsiJ  sdJ  ni  nsss  sd  UiJa   /un: 

.woled  39!  9fli  lo  ofnri  miai 

-1U09T  on  Imfi  oLfim  R«W  dq/5igoil)«-i  gidi  soiria  i/;9v;  ji  yl'icofi  ?.r  if 
.§ni,Hoqqirfc-l[9e  IMIJ;  Lav'ilqms  v/on  tii  JnsiJcq  edT    .ooiifq  iro;h 


V. 


FIG.  52.— DIRECTION  OF  BISMUTH  PASTE. 


FIG.    53 

FIG.  53  shows  a  radiograph  of  a  tubercular  hip  joint  with  only 
one  discharging  sinus  at  a.  In  spite  of  a  course  of  tuberculin  and 
vaccine  treatment  the  sinus  failed  to  heal  and  the  child  suffered  recur- 
rent attacks  of  temperature  ranging  between  103°  and  105°  F.  lasting 
from  one  to  two  weeks.  A  stereoradiograph  taken  immediately  after 
bismuth  was  injected  under  pressure  irevealed  the  fact  that  the  channel 
opens  into  a  cavity  directly  above  the  fistulous  opening.  This  cavity 
communicates  with  a  smaller  cavity  behind  the  ileum,  which  in  turn 
communicates  with  a  third  cavity  by  means  of  a  channel  running 
through  the  joint.  The  third  cavity  filled  with  bismuth  was  easily 
felt  as  a  mass  on  the  buttock.  Under  a  local  anesthesia  a  small  inci- 
sion was  made  on  the  buttock  directly  over  the  third  cavity  as  indi- 
cated by  6.  Almost  immediately  after  this  procedure  the  local  con- 
dition improved  rapidly  and  soon  healed.  No  temperature  has  occurred 
since. 


83    .oil 


"{Ino    rfliw   .Jflioi;   qirf   islimaduj    a   io    dqBigoibuT    B   eworia   £5    .oil 
brtB  nilrmodui  Jo  sainoa  B  lo  aliqa  nl.     .n  JB  aimia  gnigiBrfoeib  sno 
-TU09T  ho'isltoa  blirlo  sift  bns  Ifisd  od  bsliel  eunia  edJ 

/i  °f,OI  bns  °80f  nesv/Jed  gni^nBi  siuiBisqai^  \o 

[siBibammi  n9>lBJ  /fqcigoibfiiosiaJa  A     .ejfeew  owi  oi  sno 
oifi  inrft  io«l  9ffi  Iwlfievst  oit/aesiq  igbno  b6Jo9yii  BBW  rfJurneid 

stiJT  .T>niif9qo  auofuigft  srfj  evods  ^Woaiib  ^JivBO  B  oJni  enaqo 
mo}  ni  riohf-w  tmu9li  arfi  bnirfsd  ^iivBO  i9llBni8  £  rfiiw  gajfioimjmraoo 
^>(iinrrm  fgnnnrfo  B  lo  en«9fn  *^d  ^iyjso  btiitt  a  riJiw  esiBoini/ramoo 
^fiace  KR-II  ittumsid  dim  bellit  ^iivBO  Inirfi  ariT  .inio'i  srfi  riguoirfi 
-ioni  Hfima  n  Bi«9rfJ&9nB  IBOO!  B  labnU  .jlotxiiod  srfi  no  agBin  »  EB  ibl 
-ibni  SK  viivBa  biiri*  9rfd  i9vo  ^lioa'iib  >IooWud  arf^  no  sbBrre  BBW  noia 
-noa  IBOO!  9ffJ^  giubgooiq  ehlj  loils  ^Isifiibsmmi  JgomfA  .6  x^  b9iaa 
bennooo  acil  g-mi/noqmg}  ol/L  ,fj9ffi9({  nooa  ban  ^IbiqBi  bsvoiqrai  noiJib 


FIG.  53. — DIRECTION  OF  BISMUTH  PASTE. 


FIG.  54. — DIRECTION  OF  BISMUTH  PASTE. 

FIG.  54  is  a  photograph  of  the  same  hip  as  radiograph,  Fig.  53, 
with  a  schematic  outline  of  the  tuberculous  tract,  the  solid  area  show- 
ing the  anterior  and  the  ruled  area  the  posterior  part  of  the  tract. 
The  heavy  dot  represents  the  fistulous  opening  artificially  made. 


FIG.    55 

A  young  man  twenty-two  years  old,  with  a  negative  family  history, 
had  nothing  in  his  past  history  that  had  any  bearing  on  his  present 
complaint,  except  that  he  had  had  measles  and  scarlet  fever.  His 
present  complaint  began  five  years  ago  with  the  formation  of  an 
ischiorectal  abscess  which  refused  to  heal  and  "was  operated  upon  for 
fistula-iuano.  The  fistula,  however,  recurred  and  persisted  for  several 
years.  A  second  extensive  operation  with  no  better  results  waa  per- 
formed a  year  before  he  came  to  me  for  treatment.  The  usual  routine 
as  to  tuberculin,  vaccine,  and  bismuth  paste  was  carried  out.  But  in 
spite  of  increased  weight  and  strength,  and  in  ispite  of  the  fact  that 
he  was  able  to  return  to  full  duty  at  his  occupation  (which  he  had  not 
been  able  to  do  for  years),  the  local  condition  did  not  completely  heal. 
There  was  only  one  large  fistulous  opening  into  which  about  three 
drams  of  bismuth  'paste  could  be  injected,  but  the  fistula  was  still 
there  at  the  conclusion  of  the  tuberculin  treatment.  After  careful 
radiographic  study  one  fistula  was  found  to  lead  to  the  sacrum.  A 
puncture  incision  was  made  at  that  point  and  the  bismuth  paste  in- 
jected at  the  new  opening  until  it  appeared  at  the  old  opening  as 
shown  in  this  photograph.  In  less  than  two  weeks  the  discharge 
stopped.  The  local  condition  improved  more  in  the  next  two  weeks 
than  it  had  in  the  six  months  of  previous  treatment. 


5S    .Oil 

,7'ioiairf  vjimfil  9vida§9n  f>  rfiiw  <blo  eiB9^  owd-^Jn9wJ  rrsm  giiuo^  A 
dn9«nq  eirl  no  ^nriBod  ^nn  bttA  dBffJi  ^loieid  d?.Bq  aid  ni  gnidJon  bad 
?iFi     .-1979!   ial'iBoa    baa   Ksl&sem   bfid   b«d   9rl   JBdd   iq99Z 
rir.    lo    aoiJjjirnol    oifi    rfjiw    O§B    eiB9^    svft    iiBgad    iniBfqraoo 
•ioi   noqi;  bgiB'iyqo  HBV/  bris  I^Sff  oi  b98i/l9'i  rfoiifw  segoedB  lBdD9'ioiiio8i 
tot  batafrnsq  birB  b9m/o9i  ti9V9WorI  .eluteft  9ifT     .onBti 
011  riJiw  noiiBigo  9via«9Jx9  bno»9a  A 


ni  intl  Jffo  bsrnno  BBW  eiajsq  ffinmeid  bna  ,9ni90BT;  tniljjoi9di/i  oJ  an 
ii::!i  iyr.t  9/Ii  lo  siiqa  ni  bnn  ,riJgH9'iia  bna  ^ilgigw  b98«9T9iii  lo  giiqa 
Jm  ijr.ii  oil  riohfw)  noiiiiqijooo  sirf  ^B  ^iub  ilul  od  mui9i  oi  aldfi  SBW  grf 
.[nod  ^laiolqmoo  ion  bib  noitibnoo  IBDO!  ?>ilj  ,(KIB'J^  tol  ob  oJ  gfdfl  a99d 
irodK  rf'jiil/A  oJni  gnirigqo  suoli;;t«rt  9gial  9no  ^Ino  BBW  9i9dT 
?.r,-ff  Bliiien  9(iJ  dud  tbdtosiai  9d  bli/oo  gieBq1  ifJumaid  lo  emmb 
ii-j  Tjjl/.  .Ifi'jfiiifmi  niIiJ9i9diJd  9di  lo  noieulonoo  9ffi 
/  .ifirr-ioiia  rn\J  o1  bra!  od  bnnol  ejrw  BluJ^it  9fro  "^bi/t 
-ui  'jtixsq  iWirniriid  9ilj  bnB  inioq  i«di  da  9bBtn  BBY/  noi&ianr 
Kf:  v.ftinoqo  bio  -xli  d«  bgussqqc  .ii  Him;  gningqo  W9n  9rid  JB 
f)y;if;i(-)8ib  9(ld  ?vfoow  ov/J  nxiili  eegl  ni  .rfqr.iToodoriq  eidj  ni  nwoifa 
r.>l')ov/  OY/J  ix9n  9if^  ni  9'rour  J>9vo'iqirii  noiiibnoo  IBOO!  srfT  .bgqqoia 
.1ii9mJ(;9it  Riroivnq  lo  erfdnom  xia  9rli  ni  bBd  Ji 


FIG.  55 — TUBERCULAR  COXITIS — DIRECTION  OF  BISMUTH  PASTE. 


BISMUTH  PASTE  225 

to  periodic  exposure  of  the  more  refractory  cases  that  were 
treated  with  bismuth  paste  to  the  therapeutic  X-rays.  The 
results  thus  obtained  are  sufficient  to  recommend  the  occa- 
sional exposure  of  the  bismuth  filled  tubercular  channels  to 
the  X-rays. 


15 


CHAPTER  X 
COLD  ABSCESSES 

A  cold  It  has  become  a  matter  of  principle  among  the  profes- 

pathoiogTwi        sion  to  ignore  cold  abscesses  entirely.    Whether  this  attitude 
condition  which    arose  from  fear  of  mixed  infection,  or  from  the  desire  to 

requires 

treatment.  leave  well  enough  alone,  is  hard  to  tell.     Perhaps  the  bad 

results  obtained  from  wide  incisions  and  drainage  has  led 
to  the  usual  reaction — from  doing  too  much  to  the  opposite 
of  doing-  too  little  or  nothing  at  all. 

infection  Personally  I  could  never  see  the  harm  in  emptying  a 

aspiration  cold  abscess.    As  a  result  of  the  surgical  treatment  of  a  cold 

abscess,  the  following  three  possibilities  may  arise:  infec- 
tion may  take  place;  the  abscess  may  refill;  or  the  abscess 
may  remain  empty,  the  capsule  contracting  into  a  small 
mass  of  connective  tissue. 

With  aseptic  technic  developed  to  its  present  standard, 
the  mixed  infection  need  not  form  such  an  impassable  bar- 
rier to  the  proper  treatment  of  a  cold  abscess,  especially  as 
the  methods  used  in  emptying  a  cold  abscess  here  described, 
almost  entirely  eliminate  the  danger  'of  infection.  We  do 
not  make  wide  incisions,  nor  do  we  use  drainage  tubes,  nor 
packing  such  as  is  done  in  inflammatory  abscesses  of  equal 
size. 

The  purpose  The  refilling  of  the  abscess  is  of  no  greater  consequence 

is  t0Sforestaii       than  the  recurrence  of  effusion  in  pleurisy.     It  entails  no 

the  tryptic  greater  danger  than  the  necessity  for  re-emptying.     How- 

digestion  and  *  r  •' 

inflammation       ever,  at  the  present  time,  we  even  can  to  a  large  measure 

which  irritation  ,     ,1  /?n«  p    ,1  i 

will  produce.        prevent  the  refilling  of  the  abscess. 

ISTow,  "  Why  get  rid  of  the  cold  abscess  ?  "  is  the  ques- 
tion. The  first  and  foremost  reason  is  that  a  cold  abscess 
is  a  pathological  entity  and  will  take  away  the  psycho- 
logical effect  of  the  benefit  from  tuberculin  if  it  fails  to 
absorb  during  the  healing  of  the  other  tubercular  lesions. 
Secondly,  these  abscesses  are  usually  on  the  surface  of  the 


COLD  ABSCESSES  227 

body,  and  may  become  infected  through  the  pressure  of 
clothing  or  through  outside  trauma  far  more  frequently  than 
through  the  use  of  an  aspirating  needle  which  is  always 
used  with  strict  asepsis.  In  the  third  place,  the  abscess  fre- 
quently breaks  down  through  a  tryptic  digestion  which  may 
make  its  appearance  at  any  time.  This  tryptic  digestion 
is  the  method  by  which  Mature  rids  herself  of  foreign  matter 
when  there  is  no  pyogenic  organism  present.  This  diges- 
tion usually  attacks  the  entire  surface  of  the  skin  over  the 
whole  abscess  and  produces  a  proportional  amount  of  very 
sluggish  ulcerations  with  eventual  irregular  scarring. 

A  staphylococcus  infection  is  almost  preferable  in  a 
cold  abscess  to  this  digestive  breakdown,  because  the  former 
will  point  in  but  one  place  and  an  incision  followed  by  drain- 
age will  localize  the  infection,  which  on  healing  leaves  an 
insignificant  scar.  In  the  latter  case,  the  abscess  empties 
by  a  sloughing  process  through  the  tissues,  leaving  behind 
the  most  unsightly  scars. 

Treatment 

The  best  treatment  for  cold  abscesses  is  aspiration.     An   Treatment 
ordinary  aspirating  needle  about  the  size  used  for  obtain- 


ing   spinal   fluid   is   best.      A   drop   of   tincture   of   iodine  aspiration  and 

.  the  injection 

painted  on  the  skin  over  the  dependent  part  of  the  abscess,  Of  bismuth 
and  a  little  ethyl  chlorid  spray  for  local  anesthesia,  is  all 
the  preparation  that  is  necessary.  The  needle  is  pushed 
into  the  abscess,  care  being  taken  not  to  push  it  too  sud- 
denly and  thus  injure  the  opposite  abscess  wall  and  pro- 
duce bleeding  into  the  abscess  cavity.  All  the  fluid  is 
aspirated  and  sterile  oblive  oil  injected  through  the  same 
needle,  filling  the  cavity  to  the  extent  of  about  one  quarter 
of  the  amount  aspirated.  Frequently  the  needle  tract  will 
fail  to  heal  and  will  form  a  small  fistula  through  which  any 
reaccumulation  will  slowly  ooze  until  the  capsule  entirely 
contracts. 

Another  form  of  treatment  is  by  puncture.     After  paint- 


228  TUBEBCULIN    AND    VACCINE 

in  a  very  jng  the  skin  with  tincture  of  iodine,  a  drop  of  one  quarter  of 

large  abscess  .... 

anstuious  one  per  cent,  of  cocaine  is  injected  at  the  point  where  the 


puncture  is  to  be  made.     The  same  knife  is  used  as  in  the 
by  puncture        puncture  of  soft  glands  (page  209).     then  the  abscess  is 

and  then  the 

abscess  treated     emptied  by  gentle  pressure  and  refilled  (with  sterile  olive 

with  bismuth  ,  .  .  .  ,  .  ... 

paste  injections,  oil.  The  bismuth  paste  syringe,  or  an  ordinary  medicine 
dropper  may  be  used  for  injecting  the  sterile  olive  oil.  The 
amount  of  oil  injected  should  be  about  one  quarter  of  the 
amount  of  matter  withdrawn,  or  a  quantity  sufficient  to 
keep  the  opposite  walls  of  the  cavity  from  touching,  as  any 
irritation  will  hasten  a  reaccumulation  of  pus  in  the  abscess 
cavity. 

When  puncture  is  resorted  to  instead  of  aspiration,  and 
when  the  abscess  is  not  very  large,  bismuth  paste  may  be 
injected  after  emptying.  Bismuth  often  hastens  the  con- 
traction of  the  capsule,  and  a  rapid  disappearance  of  the 
abscess  occurs  as  a  result.  The  same  may  occur  after  aspi- 
ration. A  precipitate  which  forms  in  the  fluid  content  of 
the  cold  abscess  forms  a  pseudo-lining  to  the  capsule.  The 
capsule  remaining  after  the  aspiration  of  the  fluid,  with 
a  solid  substance  within  it,  promptly  contracts,  forming  a 
nodule  which  may  protrude  from  the  surface  of  the  skin, 
The  nodule  dries  and  falls  off  after  a  few  days,  leaving  a 
smooth  circular  scar  behind. 

When  the  cold  abscess  is  very  large,  or  when  it  resisted 
the  above  treatment,  a  more  radical  procedure  is  resorted 
to  (in  fact  the  most  radical  we  ever  need  use)  consisting  of 
an  incision,  never  more  than  one-fourth  to  one-half  an  inch 
long,  and  followed  by  drainage.  As  a  drain,  a  few  strands 
of  silk  or  a  very  narrow  strip  of  rubber  tissue  is  used.  In 
forty-eight  hours  we  have  established  a  fistula  and  now  can 
treat  the  cold  abscess  as  we  treat  bone  cavities.  Bismuth 
paste  is  injected  every  forty-eight  hours,  care  being  taken  to 
remove  first  any  bismuth  paste  which  has  not  oozed  out  from 
the  previous  injection.  Even  a  thirty  per  cent,  bismuth 
paste  may  be  used  here. 


COLD  ABSCESSES  229 

Under  no  circumstances  should  a  cold  abscess  be  packed  Gauze  packing 

with  gauze,  nor  should  drainage  with  rubber  tubing  or  gauze  by  means  of 

ever  be  resorted  to.      The  danger  of  infection  is  far  less  J^,,, 

when  the  cold  abscess  is  left  without  drainage  altogether.  sauze  should 

be  avoided. 

We  may  reduce  the  danger  of  infection  still  further  by 
means  of  an  alcohol  compress  applied  to  the  incision  after 
each  treatment,  and  by  means  of  scrupulous  care  in  steriliz- 
ing the  syringe  and  the  bismuth  before  use.  I  have  had  no 
serious  trouble  with  infections  in  treating  cold  abscesses  in 
the  manner  just  described,  although  I  have  opened  a  great 
many  over  a  period  of  eight  years.  i 

It  is  far  better,  however,  to  leave  cold  abscesses  entirely 
alone,  than  to  treat  them  improperly.  The  following  case 
is  an  example  of  the  serious  hartm  that  can  be  done  by  the 
application  of  the  usual  surgical  principles  to  cold  abscesses : 

The  patient,  a  man  twenty-one  years  of  age,  with  an  old  Example, 
tubercular  lesion  in  the  dorsal  spine,  developed  a  large  cold 
abscess  occupying  the  entire  posterior  surface  of  the  left 
thigh.  Without  any  special  indication  for  surgical  inter- 
ference, an  operation  was  decided  upon.  The  patient  was 
taken  to  a  hospital  and  under  ether  anesthesia,  a  two-inch 
incision  was  made  at  the  upper  end  of  the  abscess,  another  at 
the  lower  end,  and  a  rubber  tube  pulled  through  and  left 
protruding  from  both  incisions,  in  order  to  insure  perfect 
drainage.  The  patient  had  no  temperature,  and  I  believe 
the  lesion  in  his  spine  was  not  active.  Three  days  after 
the  operation,  the  patient  developed  a  temperature  of 
105.5°  F.  with  a  typical  streptococcus  septicemia.  After 
the  infection  persisted  [for  a  week  or  over,  the  patient's  con- 
dition became  alarming,  and  I  was  called  in  to  institute 
vaccine  treatment.  An  immediate  removal  of  the  rubber 
tube  and  a  thorough  washing  out  of  the  cavity  with  alcohol, 
together  with  the  use  of  a  streptococcus  vaccine,  soon  placed 
the  infection  under  control.  In  a  week,  normal  tempera- 
.ture  was  again  restored.  I  am  quite  certain  that  had  one  or 
two  punctures  been  made  for  the  escape  of  the  fluid,  followed 


2:jO  TUBERCULIN  AND  VACCINE 

by  the  injection  of  a  bland,  oily  substance  to  prevent  the 
rubbing  of  the  opposite  walls,  the  abscess  could  have  been 
healed  without  any  trouble. 

I  might  add  here,  that,  owing  to  the  size  of  the  abscess 
(it  held  nearly  a  pint  of  fluid),  it  would  have  been  .against 
the  best  interest  of  the  patient  to  have  omitted  treatment 
altogether,  although  no  treatment  would  have  been  better 
than  what  the  patient  first  received.  When  the  digestive 
process  sets  in,  the  sloughing  of  the  skin  over  the  abscess 
is  so  extensive  that  great  discomfort,  lasting  for  months  on 
account  of  the  slow  healing  ulcerations,  is  produced. 


CHAPTER  XI 
EMPYEMA  AND  LUNG  ABSCESS 

Purulent  effusion  in  the  pleural  cavity  is  a  complication 
in  tuberculosis  that  occurs  in  four  different  ways : 

(1)  Infection  of  serous  effusion; 

(2)  The  pointing  and  breaking  of  a  pulmonary  abscess 
into  the  pleural  cavity; 

(3)  The  ulceratiou  of  a  pulmonary  cavity  and  its  open- 
ing into  the  pleural  cavity ; 

(4)  The  infection  of  the  pleural  cavity  by  the  extension 
of  a  mixed  infection  from  tuberculosis  of  the  ribs  or  spine. 

A  lung  abscess  complicating  phthisis  may  communicate 
with  a  large  bronchus  and  drain  by  means  of  cough  and 
expectoration ;  it  may  communicate  with  the  pleural  cavity ; 
and  it  may  communicate  with  both  with  the  bronchus  and 
the  pleural  cavity. 

The  bacteriology  of  empyema  and  lung  abscess  is  apt 
to  be  very  complicated  unless  treatment  is  applied  early 
when  the  bacteria  concerned  in  the  etiology  of  the  infection 
decidedly  predominate  and  are  easily  recognized.  The  fol- 
lowing are  the  bacteria  which  are  mainly  concerned  in  these 
processes : 

Streptococcus 
Pneumococcus 
M.  catarrhalis 
M.  tetragenus 
B.  Friedlander 
B.  coli 
B.  proteus 
Staphylococcus 
B.  pyocyeneus 
B.  influenza 


232  TUBERCULIN  AND  "VACCINE 

Treatment 

Treatment  consists  of  three  distinct  measures  whick 
should  be  applied  together  ("  combined  ")  as  each  has  its 
distinct  indication.  As  is  true  in  all  forms  of  tuberculosis, 
treatment  can  only  be  effective  in  the  largest  number  of 
cases  when  the  combined  methods  are  used.  These  methods 
are: 

\raccines  against  the  infection; 

Modified  surgical  measures  for  drainage  or  ;for  the 
removal  of  purulent  materials; 

Treatment  of  the  condition  for  the  prevention  of  reaccu- 
mulation  of  purulent  material  and  for  the  stimulation  of 
the  healing  process. 

Vaccines  Against  the  Infection.  The  vaccine  treatment 
of  purulent  effusions  or  pulmonary  abscesses  is  the  same  as 
the  vaccine  treatment  in  acute  pulmonary  mixed  infections 
both  as  to  dosage  and  intervals  (see  page  193).  However, 
the  local  treatment  of  the  condition  is  far  more  important 
than  the  vaccine  treatment.  The  purulent  accumulation  is 
so  large  in  quantity  that  the  bacterial  growth  can  take  place 
in  spite  of  a  sufficient  immune  response.  The  bacterial 
growth  occurs  beyond  the  reach  of  the  defensive  substances 
of  the  individual.  When  the  antibodies  do  enter  into  the 
large  effusions  they  become  so  diluted  that  only  a  small 
proportion  of  the  invading  organisms  are  reached. 

Modified  Surgical  Measures  for  Drainage  or  for  the 
Removal  of  Purulent  Materials.  Although  drainage  is  of 
primary  importance  in  the  treatment  of  both  purulent  effu- 
sions and  pulmonary  abscesses  it  is  unnecessary  to  resort  to 
radical  surgical  measures  such  as  are  employed  where  sur- 
gery is  the  only  measure  instituted  for  the  relief  of  the 
condition.  Through  the  application  of  the  combined  meas- 
ures for  controlling  the  infection,  the  -removal  of  the  puru- 
lent accumulation  and  the  prevention  of  reaccumulation,  the 
surgical  measures  can  be  greatly  modified.  It  is  sufficient 
to  make  a  half  inch  incision  under  cocain  or  novocain  anes- 


EMPYEMA  AXD  LUNG  ABSCESS  233 

thesia  in  an  intercostal  space  for  the  passage  of  a  medium 
sized  catheter  through  which  the  purulent  effusion  may 
be  aspirated,  using  for  this  purpose  either  a  syringe  or 
vacuum  suction.  Through  the  same  catheter,  warm  sterile 
normal  saline  should  be  injected  several  times  and  again 
aspirated  in  order  to  wash  out  the  abscess  or  pleural  cavity. 
This  procedure  should  be  repeated  daily  until  the  fluid  with- 
drawn is  no  longer  purulent. 

Local  Treatment  for  the  Prevention  of  Reaccumulation 
of  the  Purulent  Materials  and  for  the  Stimulation  of  the 
Healing  Process.  After  the  abscess  or  pleural  cavity  is 
emptied  and  wrashed  of  purulent  material,  sterile  olive  oil 
should  be  injected  and  left  in  the  cavity  until  the  next  treat- 
ment. The  quantity  of  olive  oil  injected  should  be  about 
one-half  of  the  amount  of  purulent  fluid  withdrawn,  except 
in  cases  where  the  pulmonary  abscess  communicates  with 
the  bronchus.  In  that  case  the  olive  oil  should  be  injected 
until  coughed  up  through  the  mouth.  The  distress  and 
vomiting  produced  by  the  foul  discharge  coming  up  through 
the  bronchus  almost  entirely  disappears  after  the  injec- 
tion of  olive  oil.  In  cases  of  purulent  pleurisy  and  in 
cases  of  pulmonary  abscess  where  the  communication  with 
the  bronchus  still  exists,  vaccines,  cleansing,  and  olive  oil 
injections  are  sufficient.  In  case  of  a  pulmonary  ab- 
scess which  becomes  adherent  to  the  parietal  pleura  and 
communicates  directly  with  the  surface  of  the  body,  and 
where  the  communication  with  the  bronchus  has  healed  over 
or  never  existed,  bismuth  paste  should  be  employed.  Be- 
ginning with  Formula  1  bismuth  paste  (page  219)  the  subse- 
quent injections  should  be  made  with  the  stronger  formulas 
if  no  tendency  of  bismuth  poisoning  has  appeared.  By 
means  of  olive  oil  injections  the  bismuth  can  be  easily 
washed  out  in  case  of  poisoning. 

In  the  following  three  illustrations  will  be  found  typical 
examples  of  each  of  the  three  different  forms  of  pulmonary 
abscesses:  one  communicating  with  the  pleura  and  produc- 


TUBERCULIN  AND  VACCINE 

ing  a  purulent  pleurisy;  one  communicating  with  the 
bronchus  allowing  of  vaccine  treatment  only ;  one  com- 
municating with  both  the  pleura  and  bronchus.  I  have 
added  a  fourth  illustration  to  emphasize  the  necessity  of 
radiography  for  the  diagnosis  of  these  conditions.  This 
patient  was  pronounced  hopeless  on  account  of  a  pulmonary 
abscess  and  purulent  effusion,  whereas  the  radiograph  dis- 
closed the  existence  of  an  extra  pleural  pus  cavity  leading 
above  to  the  diseased  vertebra  and  running  down  to  the 
pelvis. 

FIG.  56 

A  young  woman  twenty-four  years  old  had  pulmonary  tuberculosis 
for  four  years,  and  in  spite  of  change  of  climate,  hygienic  and  dietetic 
treatment,  the  disease  progressed  until  there  was  involvement  of  the 
apex  of  the  right  lung  and  of  the  jentire  left  lung  with  a  cavity  in  the 
middle  of  the  left  lung.  Two  years  pgo  she  was  brought  to  me  for 
tuberculin  and  vaccine  treatment.  On  examination  her  case  seemed 
hopeless,  but  fearing  that  my  refusal  of  treatment  would  disclose  the 
hopelessness  of  the  condition  to  the  patient  and  thus  hasten  her  death, 
her  relatives  requested  me  to  treat  her  with  tuberculin  irrespective  of  my 
prognosis.  My  fear  was  that  the  three  trips  a  week  to  my  office  in 
order  to  get  the  treatment  would  overtax  the  strength  of  the  patient 
in  her  already  weakened  condition.  However,  the  renewed  hope  for 
cure,  together  with  a  marked  response  to  the  tuberculin  treatment  had 
a  wonderful  effect  on  the  patient. 

After  a  year  and  a  half  of  the  treatment  she  had  gained  in  weight, 
was  much  stronger  so  that  she  was  able  to  attend  to  all  her  household 
duties.  She  still  had  a  morning  cough  productive  of  sputum,  but  the 
amount  of  sputum  was  greatly  diminished  and  the  tubercle  bacilli  had 
disappeared  entirely  five  months  after  beginning  the  treatment.  The 
X-ray  findings  at  this  time  showed  the  right  lung  greatly  enlarged 
through  emphysema,  the  left  lung  greatly  contracted  and  the  cavity, 
though  still  present,  somewhat  smaller.  After  the  conclusion  of  tuber- 
culin treatment,  and  contrary  to  instruction,  she  did  not  return  at  the 
end  of  three  months  for  the  test  for  the  return  of  hypersusceptibility, 
and  for  the  examination  of  sputum  for  determining  the  renewal  of  the 
vaccine  treatment.  Six  months  later  I  was  called  to  her  home  and 
found  that  she  had  had  an  attack  of  grippe  and  for  seven  weeks  had 
a  daily  temperature  rise  to  103°  or  105°  F.  The  doctor  in  attendance 
had  pronounced  her  .condition  hopeless  for  he  could  "hear  no  breathing 
sounds  in  the  left  lung  and  considered  it  a  case  of  tubercular  pneu- 
monia. As  three  weeks  had  passed  and  the  patient  was  still  in  the 
same  condition,  I  was  called  in  for  consultation.  The  first  glance  at  the 
patient  was  sufficient  to  discover  that  the  left  pleural  cavity  was  tre- 


EMPYEMA  AXD  LU^G  ABSCESS  235 

memiously  distended  with  fluid.  Examination  showed  that  her  heart 
pushed  to  the  right,  and  the  chest  which  had  been  retracted  on  the  left 
side  was  now  decidedly  bulging.  An  aspirating  needle  brought  out  a  very 
thick  foul  smelling  pus.  Owing  to  the  cyanotic  and  dyspneic  condition  of 
the  patient,  I  decided  to  drain  the  pleural  cavity  at  once.  After  cocain 
infiltration,  a  stab  incision  was  made  in  the  seventh  interspace  on  the  left 
side  of  her  back.  Ninety-eight  ounces  of  pus  were  withdrawn,  and  through 
a  soft  rubber  catheter  one  quart  of  sterile  olive  oil  was  injected.  For  the 
next  ten  days  the  pleural  cavity  was  emptied  through  this  catheter, 
washed  out  with  normal'  saline  and  refilled  with  a  constantly  decreasing 
amount  of  sterile  olive  oil.  At  no  time  was  a  drain  of  any  kind  left 
in  the  incision.  Two  days  after  the  incision  was  made  the  temperature 
dropped  to  normal  and  remained  there. 

The  above  radiograph  was  taken  one  month  after  the  discontinua- 
tion of  all  local  treatment  of  the  abscess.  It  corroborated  the  earlier 
conclusion  that  the  cavity  had  ulcerated  through  and  broken  into  the 
pleural  cavity,  that  the  lung  had  become  adherent  to  the  pleura  after 
the  pus  had  been  withdrawn,  and  that  the  lung  cavity  is  in  direct  com- 
munication with  the  external  fistulous  opening.  The  bismuth  paste 
which  was  injected  for  this  X-ray  photograph  entered  directly  into  the 
lung  abscess. 

An  important  point  which  this  case  brings  out  is  the  fact  that  the 
communication  between  the  original  lung  cavity  and  the  bronchus 
healed  across  immediately  after  the  drainage  of  the  pleural  cavity. 
The  cough  and  expectoration  which  persisted  after  the  tuberculin  and 
vaccine  treatment  now  disappeared.  The  patient  declares  that  she  is 
better  than  she  has  ever  been  since  the  beginning  of  her  illness.  The 
most  prominent  bacteria  found  in  the  pus  of  the  pulmonary  abscess, 
and  for  which  vaccines  were  made  were  the  streptococcus,  m.  catarrhalis 
and  the  pyocyaneus. 


236  TUBERCULIN  AND  VACCINE 

FIG.    57. 

Over  a  period  of  four  years  this  patient  had  repeated  attacks  of 
"  pneumonia "  lasting  from  one  to  three  weeks,  and  characterized  by 
bloody  sputum,  high  temperature  and  dyspnea.  Each  attack  left  him 
with  a  severe  cough  which  was  productive  of. a  large  amount  of  foul 
smelling  expectoration,  and  which  lasted  for  varying  lengths  of  time. 
Every  time  the  cough  ceased  there  would  be  a  fresh  attack  of  "  pneu- 
monia." The  fifth  attack  was  accompanied  by  an  unusual  amount  of 
blood  in  the  expectoration  leading  to  the  diagnosis  of  tuberculosis  and 
the  reference  of  the  case  to  jme.  The  nature  of  the  patient's  tempera- 
ture curve  was  typical  of  pyemia.  His  temperature  ranged  from 
normal  in  the  morning  to  103°  and  ,105°  F.  in  the  afternoon.  There 
was  distinct  dullness  over  the  middle  right  lung,  and  it  had  been 
noticed  that  all  the  pneumonic  proceses  always  localized  in  the  same 
place  and  never  spread  beyond  it.  This  temperature  curve,  the  patient's 
history,  and  character  of  his  sputum  led  to  the  diagnosis  of  lung 
abscess  draining  through  a  bronchus.  The  X-ray  confirmed  this 
diagnosis. 

An  autogenous  vaccine  was  made  of  the  streptococcus  and  pneumo- 
coccus  found  in  the  sputum,  and  after  the  first  dose  of  forty  million 
streptococcus  and  twenty-five  million  pneumococcus,  the  temperature 
came  down  to  normal.  Although  it  may  be  claimed  that  the  tempera- 
ture came  down  after  the  establishment  of  proper  drainage  through 
the  bronchus,  as  in  previous  attacks,  it  cannot  be  denied  that  the 
complete  healing  was  brought  about  by  the  vaccine.  That  the  patient 
is  cured  is  evidenced  by  a  gain  of  over  twenty-five  pounds  in  weight, 
the  disappearance  of  the  cough  and  expectoration  soon  after  the  tem- 
perature was  reduced  to  jnormal.  Although  there  was  no  recurrence  of 
"  pneumonia  "  for  over  a  year,  a  course  of  tuberculin  treatment  was 
also  administered  as  the  original  cause  of  the  abscess  was  no  doubt 
tubercular  in  nature.  During  the  tuberculin  treatment  the  tubercular 
process  in  the  apex  of  the  right  lung  and  in  the  upper  half  of  the  left 
lung  cleared  up. 

The  above  radiograph  was  taken  after  the  expectoration  became 
profuse  and  the  abscess  had  more  or  less  emptied.  The  abscess  would 
show  more  distinctly  if  the  radiograph  had  been  taken  two  days  earlier. 


FIG.  57. — Pulmonary  abscess  draining  into  a  bronchus. 


EMPYEMA  A^D  LUNG  ABSCESS  237 

FIG.  58. 

During  a  mild  tubercular  lesion  in  the  apex  of  the  right  lung  the 
patient  suffered  an  attack  of  lobar  pneumonia  involving  the  entire  right 
lung.  This  attack  terminated  by  lysis  and  finally  developed  into  a 
typical  case  of  unresolved  pneumonia  which  after  six  weeks  was  finally 
recognized  as  a  pulmonary  abscess.  The  temperature  at  this  time  was 
of  the  septic  type  rising  daily  to  104°  and  105°  F.  with  marked  dysp- 
nea. An  Estlander  operation  was  immediately  advised  but  the  patient's 
family  refused  on  account  of  the  bad  prognosis  rendered  by  a  number 
of  physicians.  When  I  first  saw  the  patient  he  was  in  the  most  desper- 
ate condition,  cyanosis  and  dyspnea  were  marked.  He  was  greatly 
emaciated  not  only  on  account  of  his  disease  but  on  account  of  his 
inability  to  partake  of  any  kind  of  food.  His  expectoration  was  so 
copious  and  so  foul  smelling  that  it  would  bring  about  gagging  and 
vomiting  after  any  attempt  at  swallowing.  He  presented  such  a  poor 
subject  for  a  radical  operation,  that  I  had  no  hesitancy  about  offering 
as  good  a  prognosis  with  conservative  treatment.  At  the  New  York 
Polyclinic  Hospital  I  made  a  one-half  inch  incision  under  local  anes- 
thesia in  the  sixth  intercostal  space  two  and  a  half  inches  to  the  right 
of  the  spine.  The  foul  smell  of  the  discharge  which  drained  through 
this  incision  drove  all  the  attendants  out  of  the  operating  room.  The 
predominant  organisms  were  the  streptococcus  and  pneumococcus.  An 
autogenous  vaccine  was  immediately  made.  In  spite  of  daily  cleansing 
and  profuse  drainage  through  the  incision  the  patient  continued  to 
bring  up  large  quantities  of  pus.  After  three  or  four  inoculations  with 
the  autogenous  vaccine,  however,  the  discharge  changed  and  became 
mucoid  instead  of  purulent.  A  smear  made  of  the  pus  at  this  time 
showed  none  of  the  offending  organisms.  The  temperature  came  down  to 
normal.  After  five  weeks  in  the  hospital  the  patient  was  able  to  leave 
and  to  come  to  my  office  for  treatment  of  the  local  condition  of  the  ab- 
scess. Bismuth  paste  treatment  was  not  thought  advisable,  but  after  the 
injection  of  a  ten  per  cent,  bismuth  paste  for  diagnostic  purpose,  distinct 
bismuth  poisoning  appeared  (one  of  the  only  two  eases  of  bismuth  poison- 
ing I  have  ever  seen).  Owing  to  the  discovery  of  the  lead  line  at  the  gin- 
gival  margins  of  the  teeth,  olive  oil  was  used  in  order  to  wash  out  the 
bismuth  paste.  Several  ounces  of  the  olive  oil  were  injected  through 
the  incision  and  then  aspirated  with  the  bismuth  paste.  This  was  re- 
peated two  or  three  times  until  the  aspirated  oil  showed  no  further 
trace  of  bismuth,  and  to  make  certain,  olive  oil  was  injected  and  left 
in  the  abscess  cavity  to  drain  out  slowly  in  order  to  carry  with  it  any 
traces  of  bismuth  that  might  have  been  left.  It  was  thought  necessary 
for  this  purpose  to  entirely  fill  the  abscess  cavity,  hence  the  injection  was 
continued  until  the  patient  complained  of  distension.  Suddenly  he  began 
to  cough  and  brought  up  a  quantity  of  olive  oil  through  the  bronchus. 
Three  days  later  he  returned  to  the  office  with  the  report  that  on  the 
second  day  after  his  la«t  treatment  he  could  not  "  taste  "  the  smell  of 
the  pus  and  was  therefore  able  to  eat  for  the  first  time  in  months  with- 


238  TUBEBCULIN    AND    VACCINE 

out  vomiting.  As  the  pus  reappeard  on  the  third  day,  he  had  returned 
for  another  olive  oil  injection,  which  was  given  in  the  same  manner  as 
before  and  until  it  produced  the  expectoration  of  olive  oil.  Several  days 
of  comfort  followed.  All  other  treatment  was  abandoned  and  the  olive 
oil  injections  repeated  every  third  day.  After  six  such  injections,  the 
oil  was  not  coughed  up  and  the  cough  and  expectoration  stopped 
entirely.  After  three  more  injections  of  the  olive  oil  the  quantity  of 
which  was  constantly  diminishing  in  amount,  the  incision  healed  and 
the  patient  was  cured  as  far  as  the  pulmonary  abscess  was  concerned. 
During  the  four  weeks  of  treatment  with  olive  oil  he  gained  nine  pounds 
in  weight,  and  in  the  four  months  following  the  healing  of  the  abscess 
he  gained  thirty  pounds  more. 

Unfortunately  the  X-ray  picture  which  was  taken  after  the  bismuth 
injection  and  which  distinctly  showed  the  communication  of  the 
bronchus  with  the  external  incision  was  lost.  The  radiograph  repro- 
duced here  shows  the  contracted  cavity  representing  the  healed  condi- 
tion a  year  after  the  complete  cure  of  the  patient. 

This  is  the  first  instance  where  I  used  olive  oil  in  chest  conditions, 
and  I  have  used  it  ever  since  with  equal  success. 


EMPYEMA  AND  LUNG  ABSCESS  239 

FIG.  59. 

This  girl,  twenty-three  years  old,  with  a  negative  family  history,  had 
laryngeal  diphtheria  at  the  age  of  six,  and  at  eleven  pneumonia  and 
pleurisy.  After  the  attack  of  pleurisy  she  could  not  walk  without 
limping  and  the  tubercular  condition  of  her  right  hip  soon  manifested 
itself.  A  plaster  cast  was  applied  and  worn  for  about  a  year,  and  then 
replaced  by  a  brace  which  she  has  worn  ever  since.  Two  years  later, 
her  mother  noticed  a  protruding  dorsal  vertebra.  A  spinal  brace  was 
applied,  but  in  spite  of  it  pain  developed  in  the  spine,  which  increased 
in  severity  until  four  years  later  when  it  confined  her  to  bed.  A  Hibb's 
modification  of  the  Albie  operation  was  performed  and  for  about  one 
year  she  was  relieved.  Then  the  pain  recurred  all  around  the  body  at 
the  waist  line,  in  the  ribs  and  back,  and  finally  radiated  down  into  the 
left  leg  and  she  was  again  unable  to  walk.  Eight  months  later  a  fistula 
broke  open  three  inches  to  the  left  of  the  spine  at  the  lower  border  of  the 
twelfth  rib,  discharging  a  purulent  matter  ever  since.  As  soon  as  this 
discharge  began,  the  pain,  disappeared  from  the  leg  and  she  was  again 
able  to  walk. 

In  December,  1916,  she  caught  cold,  pleuritic  irritation  and  a  con- 
stant irritating  cough  developed.  Any  attempt  at  speaking  produced 
a  fit  of  coughing  and  shortness  of  breath.  Shortly  after  dyspnea  and 
cyanosis  developed.  Since  March  9,  when  she  first  began  to  take  her 
temperature  it  ranged  between  100°  and  104°  F.  She  was  at  this  time 
sent  to  a  hospital  for  advanced  pulmonary  tuberculosis,  and  the  family 
were  told  that  her  condition  was  hopeless  as  the  disease  had  extended 
to  her  lungs  where  ifc  had  produced  a  pulmonary  abscess  and  empyema. 

Four  weeks  previous  to  this  writing  I  first  saw  this  patient.  On 
the  earnest  solicitation  of  her  family  I  undertook  her  treatment.  The 
above  X-ray  disclosed  the  condition  to  be  entirely  outside  of  the  pleural 
cavity,  the  accumulation  of  the  purulent  material  producing  the  cough 
and  dyspnea  through  pressure.  The  pus,  on  examination,  disclosed 
streptococcus  and  staphylococcus  albus  to  be  the  principal  causes  of 
the  infection.  Vaccine  treatment  and  the  establishment  of  a  counter 
opening  near  the  superior  border  of  the  ileum  through  which  bismuth 
paste  is  injected,  has  improved  her  condition  by  reducing  her  tempera- 
ture to  almost  normal,  and  the  amount  of  purulent  discharge  reduced 
to  less  than  one-quarter  of  the  amount  formerly  discharged.  This 
improvement,  together  with  the  psychological  effect  brought  about  by 
the  discovery  that  her  lung  was  not  affected,  has  produced  a  remark- 
able effect  on  her  general  well-being. 


The  many  hours  of  tireless  work  which  I  bestowed 
upon  the  preparation  of  this  work  will  not  prove  in 
vain  if  I  have  succeeded,  at  least  in  some  measure,  to 
stimulate  the  spread  of  the  use  of  tuberculin  and  vaccine 
in  the  treatment  of  tuberculosis  in  general  practice. 

Certain  it  is,  that  the  conquest  of  this  wide-spread  dis- 
ease lies  in  the  hands  of  the  general  practitioner,  and  it  is 
equally  certain  that  the  final  utilization  of  the  immune 
response  is  the  best  weapon  against  this  scourge. 

That  the  signs  of  the  times  point  to  the  awakening  of 
the  medical  profession  to  these  truths,  I  can  give  no  better 
proof  than  to  quote  from  Bandelier  and  Roepke,  in  the 
conclusion  of  their  work  "Tuberculin  in  Diagnosis  and 
Treatment"  After  citing  examples  from  many  localities 
of  the  successful  institution  of  tuberculin  treatment  in 
general  practice,  they  conclude  by  saying: 

"Were  we  to  add  the  names  of  all  the  practitioners 
who,  by  word  of  mouth  or  in  writing,  have  acquainted  us 
with  their  reliance  on  tuberculin  therapy,  we  should  only 
tire  the  reader.  We  content  ourselves  with  the  recogni- 
tion that  this  is  the  sign  of  a  realization  of  what  is  really 
necessary  in  the  fight  against  tuberculosis.  For  tubercu- 
lin will  not  be  used  to  its  full  advantage  and  its  far-reach- 
ing importance  realized  if,  excluding  the  sanatoria, 
merely  a  few  doctors  make  use  of  it.  No!  Tuberculin* 
must  be  an  integral  part  of  the  medical  equipment  of  every 
physician.  It  must  be  the  Alpha  and  Omega  of  our  diag- 
nosis, prophylaxis,  and  therapy  of  tuberculosis.  Then  it 
will  fulfil  its  destiny — to  assist  in  the  extirpation  of  the 
disease.  And  in  conclusion  we  may  hopefully  give  ex- 
pression to  the  conviction  that  our  conception  of  the  far- 
reaching  importance  of  the  specific  diagnosis  and  therapy 
of  tuberculosis  will  soon  be  the  common  property  of  &11 
medical  men." 


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By  August   Bier,   translated   by  Dr.   G.   Blech.   1909.) 

16 


242  BlBLIOGEAPHY 

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f.  Gynak.,  1907,  Heft  39. 

BOSANQUET  and  EYRE.  "Serums,  Vaccines  and  Toxines."  (2nd  ed., 
London,  1910.) 

BRIEGER.  "Uber  die  Einwirkung  des  Kocih'schen  Verfahrens  auf 
Schleimhautlupus."  (Deutsche  med.  Wochenschr.,  1891,  xvii, 
200.) 

BROOKS  and  GIBSON.  "A  case  of  retrogressive  Tuberculous  Menin- 
gitis." (Lancet,  1912,  ii,  815.) 

BROWN.  "Specific  Treatment."  (Tuberculosis,  ed.  by  A.  C.  Klebs, 
London,  1909.) 

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the  Eye."  (Brit.  Med.  Journ.,  1912;  j,  589.) 

BULLOCH.  "The  Treatment  of  Tuberculosis  by  Tuberculin."  (Lancet, 
1905,  ii,  1603.) 

BUMM.  Sitzungsbericht  des  Ausschusses  des  Deutschen  Zentral- 
komitees.  Mai,  1910. 

BUSSENIUS.  "Einige  Mittheilungen  iiber  die  bisher  bei  Anwendung 
des  TE  Tuberkulins  jgesammelten  Erf ahrungen. "  (Deutsche 
med.  Wochenschr.,  1897,  xxiii,  441.) 

BUTLER.  "On  Tuberculo-toxaemia  of  the  Eye,  and  on  the  Thera- 
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Treatment  and  Diagnosis."  (The  Ophthalmoscope,  1910,  viii, 
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BIBLIOGRAPHY  243 

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DOUTRELEPONT.  "  Kurze  Mittheilung  iiber  die  bisherigen  Erfahrungen 
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' '  Das  Gesetz  der  kutanen  Tuberkulin  Eeaktion  und  ihre  An- 
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Klinik   der   Tuberkulose,   1911,   xx,   215.) 


244  BIBLIOGRAPHY 

FKIEDBERGER.     Med.  Klinik,  1910,  Nr.  13. 

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(Munch,    med.    Wochenschr.,    1909,   Ivi,    449.) 
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and  of  Tubercle  Endotoxin  on  the  Opsonic  Action  of  the  Serum 

of    Healthy    Babbits."      (Roy.    Soc.    of    Medicine    Proc.,    1910,. 

iii,   Path.  sect.   165.) 


BIBLIOGRAPHY  245 

HILLEXBERG.     ' '  Weiterer  Beitrag  zur  Entstehung  und  Verbreitung  der 

Tuberkulose."      (Tuberculosis,    1911,   x,   254.) 
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xxi,   127.) 
VAN  HOORX.     ' '  Uber  das  neue  Tuberkulin  TR  bei  der  Behandlung  des 

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HORT.     ' '  Rational   Immunization   in  the  Treatment  of  Pulmonary  Tu- 
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(Quart.  Journ.  of  Med.,  1911,  vi,  377.) 
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Tuberkulin-prap. ' '      (Kougr J    fur   ttnnere    Medizin,    Wiesbaden, 

1910.) 

JOSEPH.     "Zur  Theorie  der   Tuberkulin-Uberempfindlichkeit."  .  (Beit- 
rage  zur   Klinik   der  Tuberkulose,   1910,  xvii,   461.) 
KARO.     Contrib.  to  discussion :    ' '  Diagnose  und  Behandlung  der  Blasen 

und     Nierentuberkulose. "      (VI.    Versamml.     der     Tuberkulose 

Arzte,  Berlin,   1909.) 
"Klinische  Erfahrungen  mit  der  Kombinationstherapie  der  Nieren- 

tuberkulose. "      (Tuberculosis,    1911,   x,   273.) 
KING.  ,  "Vaccine  Therapy  in  Tuberculosis."     (New  York  Med.  Journ., 

1910,  xcii,  164.) 
KOCH,     "liber   bakteriologische   Forschung."      (Tenth   Internat.   Med. 

Congr.,  Berlin,  1890  ref.  Centralbl.  fur  Bakteriol,  viii,  563.) 
' '  Weitere  Mittheilungen  iiber   ein   Heilmittel  gegen   Tuberkulose. ' ' 

(Deutsche   med.    Wochenschr.,    1890,    xvi,    1029) ;    supplementary 

papers    (ibid.   1891,   xvii,   101   and   1189.) 

"Mittheilung  Uber  neue  Tuberkulinprap. "     (Ibid.  1897,  xxiii,  209.) 
"Uber  die  Venvertung  dieser  Agglutination."     (Ibid.  1901,  xxvii, 

829.) 
KOSSLER  and  NEUMANN.    "Opsonischer  Index  und  Tuberkulose-therapie 

nebst    Beitragen    zur    Technik    und    Dosierung    der    Tuberkulin- 

injektionen. "     (Wiener  kliii.  Wochenschr.  1909,  xxii,  1547.) 
KRAMER.       "Tuberkulin     und     Nierentuberkulose. "        (Zeitschr.     fiir 

Urolog.,   1909,  iii,  942.) 
KRAUSE.     "Die  Tuber kulintherapie  in  der  ambulanten  Behandlung  und 

bei  Fiebernden. "      (Miinchn.  med.  Wochenschr.  1905,  iii,  2523.) 
"Uber  innerliche  Amvendung  von  Kochs  Bazillen-emulsion    (Phty- 

soremid)."      (Zeitschr.  fUr  Tuberkulose,  1907,  x,  508.) 


246  BIBLIOGRAPHY 

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"  Entfieberung   mit   Bazillenemulsion. "       (Zeitschr.    fur    Tuberku- 

lose,   1909,  xv,   284.) 
KUMMELL.     "Die  chirurgische  und  spezifische  Behandlung  der  Nieren- 

tuberkulose. "      (82    Versamml.    deutseher     Naturforscher     und 

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LANDMANN.     Zentralblat  fiir   Bakteriologie,   Bd.  xxvii,   1900. 

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(Lancet,  1912,   i,   1109.) 

LATHAM  and  INMAN.     "A  Contribution  to  the  Study  of  the  Admin- 
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V.   LEUBE.     Munch.  Med.  Wochenschr.,  Nr.   31,  u.  32. 
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BlBLIOGEAPHY  24:7 

MEYER  and  SCHMITZ.  "tjber  das  Wesen  der  Tuberkulinreaktion. " 
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MILLER.  "The  Tuberculin  Treatment  of  Pulmonary  Tuberculosis  in 
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MITULESCU.  ' '  Spezifische  Substanzen  in  der  Diagnose  und  Behandlung 
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MQLLER  and  LQWEXSTEIN  and  OSTROVSKY.  ("Une  nouvelle  mSthode  de 
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MQLLERS  and  HEINEMANN.  "tjber  die  stomachale  Anwendung  von 
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NEUFELD.  Spezifische  Mittel.  Denkschr.  d.  deutschen  Zentral-Komitees 
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248  BIBLIOGRAPHY 

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INDEX 

ABSCESS                                       i  PAGE 

Formation  at  site  of  inoculations 144 

Cold 156,  226 

ACCUMULATIONS,  SERUS   (see  IRRITATIVE  ACCUMULATION) 

ACTION  OF  BISMUTH  PASTE 218 

ACTIVE  IMMUNITY    2 

ACUTE 

Af ebrile  mixed  infections 177 

Febrile  mixed  infections 173 

Mixed  infections   173 

Pulmonary  tuberculosis    Ill 

Respiratory  mixed  infections 192 

ADENITIS   (see  GLANDULAR  TUBERCULOSIS) 

AF    (ALBUMOSE  FREE  TUBERCULIN) 9 

AFEBRILE- 

Acute  mixed  infection 177 

Pulmonary  tuberculosis 112 

AGGLUTININS ; 4 

ALLERGY 5 

ANOPHYLAXIS 5 

ANEMIA 

In  bone  disease 87,  213 

ANGEL  's  DOSAGE  IN  INTRACUTANEOUS  TEST 34 

ANIMAL  INOCULATION  FOR  DIAGNOSIS  . . . . , 162 

ANTITOXINS 4 

In   tuberculosis    7 

ANTIBODIES 4 

ANTI-TUBERCULOSIS   SERUM    7 

APPLIANCES,  ORTHOPEDIC 154 

ARMY  BEPORTS  OF  TUBERCULIN  TEST 27 

ASPIRATION  \ 

In  treatment  of  cold  abscess 227 

In  treatment  of  soft  glands 209 

AUTOGENOUS  VACCINE 170,  215 

Advantages   of    170 

AUTOINOCULATION 145 

Through  exercise - 145 

Through  massage   145 

Treatment  of  147 

BACILLARY  BODIES   9 

BACILLARY  EMULSION   (BE) 9 

Method  of  making 9 

In  conclusion  of  treatment 13 


252  INDEX 

PAGE 

BACTERIA 

Catarrhal 184 

Pyogenic 184 

BANDELIER   &   ROEPKE 35 

BE    (BACILLARY  EMULSION) 9 

BEGINNING   TREATMENT 

In  glandular   tuberculosis 73 

In  lupus    140 

In  ocular  tuberculosis 139 

In  tuberculosis  of  the  ear 139 

Of  bone  and  joint  tuberculosis 90 

Of  pulmonary  tuberculosis 

Acute  or  Active 122 

Chronic 117 

Incipient 114 

Of  renal  tuberculosis 103 

Of    tubercular   peritonitis «  . .  133 

BERANECK'S  TUBERCULOL   (TBk) 11 

Bier 's    hyperemia    in 88 

BlNSWANGER,  REPORT  ON  THE  DETERMINATION  OF  THE  TUBERCULIN 

TEST 27 

BISMUTH  PASTE   86,  88,  217 

Action   of    218 

Care  of   219 

Composition   of    218 

Counter  openings  for  proper  direction 223 

Direction  of    .' 222 

Formulas  for  219 

Frequency   of   treatment   with 222 

In  bone  and  joint  tuberculosis 86,  88,  217 

In  empyema   233 

In  lung  abscess 233 

Injections  of    220 

Retention    of    221 

Syringe 220 

BONE  CAVITIES  J        i 

Mixed  infection  in  formation  of 213 

BONE  AND  JOINT  TUBERCULOSIS 85 

Anemia    in     87,  213 

Beginning  treatment  of   (see  BEGINNING  TREATMENT) 

Bier 's  hyperemia  in 88 

Bismuth  paste  in 86,  88,  217 

Cavities,  Sinuses  and  Fistulas  in 213 

Combined  treatment  of 89,  155,  213 

Conclusion  treatment  of  (see  CONCLUSION  TREATMENT) 

Genera]  hypersusceptibility  in   90 


INDEX  253- 

BONE  AND  JOINT  TUBERCULOSIS — Con.  PAGE 

Irritative  accumulations  in 88 

Mixed  infection  in  (see  MIXED  INFECTION) 

Eesults   of   treatment   in 92. 

Vaccines  in   (see  VACCINES) 

CALCAREOUS  PULMONARY  TUBERCULOSIS Ill 

CALMETTE'S  CONJUNCTIVAL  TEST 35 

CARE  OF 

Bismuth    paste     219 

Vaccines 168 

CATARRHAL  PROCESSES  IN  PULMONARY  MIXED  INFECTIONS 184 

CAUSATIVE   ORGANISM 

Diagnosis  of 161 

CAVITY,  BONE 

Formation  of 213 

Mixed  infection  in 213 

CERVICAL  ADENITIS    (see  GLANDULAR  TUBERCULOSIS) 

CHRONIC 

Mixed    infections    179 

Pulmonary    tuberculosis    110 

Kespiratory  mixed  infections 186 

CHRONICITY 180,  181,  213 

CICATRIZED   GLANDS    211 

CLASSIFICATION  OF 

Empyema 231 

Glands  for  surgical  treatment 208 

Glandular    tuberculosis    70' 

.  Lung  abscess    231 

Mixed    infections    173 

Pulmonary  tuberculosis 110' 

Respiratory    mixed    infections 186 

CLOSED  GLANDS   70 

COLD   ABSCESS    156,  226 

Examples   of   faulty  treatment   of 229-- 

Treatment    of    227 

Tryptic  digestion  in 226 

COMBINED  THERAPY  89,  155,  213,  217 

COMPOSITION  OF  BISMUTH  PASTE 218 

CONCLUSION   TREATMENT 

In  bone  and  joint  tuberculosis 91 

In   glandular  tuberculosis 74 

In  lupus 141 

In   ocular   tuberculosis .' 139 

Of  acute  or  active  pulmonary  tuberculosis 122 

Of  chronic  pulmonary  tuberculosis 118 

Of   incipient   pulmonary   tuberculosis 114 

Of  renal  tuberculosis 103 


254  INDEX 

CONCLUSION  TREATMENT — Con.  PAGE 

Of   tubercular   peritonitis. 133 

Of  tuberculosis  of  the  ear 139 

With  vaccines 179 

CONDITIONS,   SPECIAL    142 

CONJUNCTIVAL  TUBERCULIN  TEST 35 

CONSTITUTIONAL  KEACTION 5,  39,  53,  56,  59,  61,  63,  80,  142 

Appearance  of  sputum 20 

Differentiation    of    142 

CONTAGIOUS  DISEASES 

Contraindication   to  -test 25 

Increased  hypersusceptibility  after 150,  151,  152 

CONTAINERS 

For  tuberculin   dilutions 47 

For  vaccines    . . . .  '. 166 

CONTRAINDICATIONS   TO   TUBERCULIN 21,  24 

FOR  TEST 

In  contagious  or  infectious  diseases 25 

In  epilepsy   25 

In  fever    25 

In  general  miliary  tuberculosis 25 

In  heart  disease ". 24 

In   hemoptysis    26 

In  intestinal  ulcerations 25 

In    nephritis    24 

To   conjunctival   test 36 

FOR  TREATMENT 

In  pulmonary  tuberculosis 108 

Of    debility    . 109 

Of  fever    108 

COUGH,  EFFECT  OF  TUBERCULIN  ON 128 

COUNTER  OPENINGS  FOR  PROPER  DIRECTION  OF  BISMUTH  PASTE.  .  223 
COXITIS,  TUBERCULAR   (see  Fig.  55) 

CULTURES  FOR  DIAGNOSIS 161 

CUTANEOUS  TUBERCULIN  TEST  OF  VON  PIRQTJET 28 

Interpretations  of  29 

Negative  findings  in 30 

Positive  findings  in 31 

Traumatic  reaction  in 29 

Variations    in     30 

DEBILITY 109 

DEFORMITY,  TREATMENT  OF 89 

DETERMINATION  OF  TUBERCULIN  TEST • 26 

Army    reports    of 27 

Binswanger's   report    of 27 

DIAGNOSIS 

Animal   inoculation  for 162 


INDEX  255 

DIAGNOSIS — Con.  PAGE 

Cultures  for   161 

Difficulty  of,  in  renal  tuberculosis 98 

Early,    in    renal    tuberculosis 98,  99 

Of    infective    organism 158 

Physical  signs  in 162 

Smear 159 

Tuberculin  reaction  in 17,  20 

Tuberculin,  in  renal  tuberculosis 98,  99 

DIETETICS 200 

DIGESTION 

Effect   of   tuberculin   on 127 

Tryptie,  in  cold  abscess 226 

DILUENT 14 

DILUTIONS  OF  TUBERCULIN 13,  14,  47 

Containers  for  47 

Directions  for  making 14 

Eeady  made   16 

Stability  of 15 

Tables  of   15 

DIRECTION  or  BISMUTH  PASTE,  PROPER 

Counter    openings    for • 222 

Roentgenography  for  224 

DOSAGE 

Effects  of  reaction  on 55,  56,  59 

Explanation  of  methods  of 54 

Of  tuberculin  in  tests 20 

Of  Vaccine   (see  VACCINE  DOSAGE) 

Principles  in  treatment 52,  53 

Tables  of   (see  TABLES) 

DRESSING  FOR  BISMUTH  PASTE  EETENTION 222 

EAR  TUBERCULOSIS   139 

EFFECT  OF  TUBERCULIN 

As  demonstrated  by  x-ray  findings 130 

On   cough    128 

On   digestion    127 

On    expectoration    129 

.On  fever  128 

On  hemoptysis   129 

On  pain   ,  .  -. 127 

On   pathology    130 

On  physical  signs 129 

On  pulse  

On  symptoms  127 

On  temperature  128 

On   weight    127 


256  INDEX 

PAGE 

EFFUSION,   TREATMENT  OF 

Peritoneal 137 

Pleural 132 

Purulent 231 

EMPYEMA 

Bismuth   paste  in 233 

Classification   of    231 

Olive   oil   in 233 

Prevention  of  purulent  reaccumulation 233 

Stimulation  of  healing  process  in 233 

Surgical  treatment  of 232 

Treatment    of    232 

Vaccines  for 232 

EPILEPSY,   CONTRAINDICATION    TO   TUBERCULIN    TREATMENT 25 

EQUIPMENT 42 

ESCHERICH  's  NEEDLE  TRACT  REACTION 32 

EXPECTORATION,  EFFECT  OF  TUBERCULIN  TREATMENT  ON 129 

EYE    TUBERCULOSIS    137 

FEBRILE 

Pulmonary    tuberculosis     112 

Mixed    infection    173 

FEVER    (see    TEMPERATURE) 

FIBROUS  PHTHISIS Ill 

FILTRATES,  TUBERCULAR  8 

FINDINGS    (see  NEGATIVE  or  POSITIVE  FINDINGS) 

FISTULAS 

Combined    treatment    for 213,  217 

Formation   of    213,  217 

Mixed  infection  in <.  . .  .  .  213 

FOCAL   REACTION    19,  40 

As  an   aid   to  vaccine   treatment 179 

FORMULAS 

For  bismuth   paste 219 

For  chemical  method  of  softening  cicatrized  glands 212 

FREQUENCY 

Of  Bismuth  paste  injections 222 

Of   micturation   in   renal   tuberculosis 99 

GENERAL  HYPERSUSCEPTIBILITY  (see  HYPERSUSCEPTIBILITY) 

GENERAL  MILIAR Y  TUBERCULOSIS 2,5 

GENERAL   PROPHYLAXIS    198 

GENITO-URINARY  TUBERCULOSIS  (see  RENAL  TUBERCULOSIS) 
GLANDS 

Cicatrized 211 

Closed 70 

Open 71 

Radical    surgical    treatment    of 72,  74 


INDEX  257 

GLANDS — Con.  PAGE 

Soft 208 

Suppurating 210 

GANDULAR   TUBERCULOSIS 

As  primary  infection 68 

Beginning   tuberculin   treatment   in 73 

Best   to   acquire   tuberculin   technique  in 66 

Classification    of    70 

Closed  glands 70 

Open    glands    71 

Recurrent    glands    71,  74,  83 

Conclusion  of  tuberculin  treatment  in 74 

General  hypersusceptibility  in 72 

Eesults  in   74 

Surgical  treatment  of 208 

Treatment  of  mixed  infection  in.  . . 210 

HEART  DISEASE   24 

HEMOPTYSIS 26 

Contraindication  to  tuberculin  test 26 

Effect   of   tuberculin    on 129 

HEMORRHAGIC  PULMONARY  TUBERCULOSIS  112 

HOECHST  's  TUBERCULIN   SERUM 7 

HYGIENE,  PERSONAL   200 

HYGIENIC-DIETETIC-CLIMATIC  TREATMENT  IN  PULMONARY  TUBER- 
CULOSIS   107 

HYPEREMIA 

Bier's 86,  88 

Of  focal  reaction 19,  40,  179 

HYPERSUSCEPTIBILITY 5,  19,  52 

General,   in   glands 72 

In  bone  and  joint  tuberculosis 90 

Increased  by  radical  operation 69,  72 

Increased  by  contagious  or  infectious  diseases. . .  .25,  150,  151,  152 

In  pulmonary  tuberculosis 112 

In   renal   tuberculosis 101 

Test  for  recurrence  of 147 

IDIOPATHIC  PLEURISY   132 

IMMUNE  RESPONSE 

To  tuberculin   4,  5,  6 

IMMUNITY 1 

Active 

Passive 

IMMUNIZATION,  PROPHYLACTIC    78,  195 

INCIPIENT 

Pulmonary  tuberculosis   HO 

Renal   tuberculosis    97 

17 


258  INDEX 

PAGE 

INCUBATION.  .  161 

INDICATION  FOR  TUBERCULIN  TESTS 18 

INFECTIONS,  MIXED   (see  MIXED  INFECTIONS) 

INFECTIONS,  ELIMINATION  OF  SOURCE  OF 198 

INFECTIOUS  DISEASES   ;. . .« 25,  150,  151,  152 

INJECTIONS  OF  BISMUTH  PASTE 220 

INOCULATION,  ANIMAL  162 

INSTRUCTIONS  TO  PATIENTS 

In  proper   dressing  for  bismuth  retention 222 

In   taking   of   temperatures 48 

INTERPRETATION  ;  | 

Of  cutaneous  tests 29 

Of   tuberculin  tests 19 

INTOLERANCE  TO  TUBERCULIN 144 

INTERVALS 

Effects  of  reaction  on 55,  59 

In  bismuth  paste  injections 222 

In   tuberculin   treatment 55 

In    vaccine    administration 174,  178 

INTRACUTANEOUS  TESTS 33 

INTESTINAL  ULCERATIONS   25 

IRRITATIVE  ACCUMULATIONS  , 

In  bone  and  joint  tuberculosis 88 

Serus 88 

JOINT  TUBERCULOSIS  (see  BONE  AND  JOINT  TUBERCULOSIS) 
KIDNEY  TUBERCULOSIS   (see  EENAL  TUBERCULOSIS) 

LANDSMANN  TUBERCULOL   10 

LAPAROTOMY  FOR  TUBERCULAR  PERITONITIS 133 

LOCAL  KEACTION    19,  39 

LUNG  ABSCESS 

Bismuth  paste  in 233 

Classification  of    231 

Cumulations 232 

Examples!  of  various  forms  of 235 

Olive  oil  in  treatment  of 233 

Prevention  of  purulent  reaccumulations 233 

Surgical  treatment  of 232 

Treatment  of  232 

Vaccines  in 232 

LUNG  TUBERCULOSIS  (see  PULMONARY  TUBERCULOSIS) 

66,  140 

Beginning  and  conclusion  treatment  of 140 

Local    treatment   of 140 

Reactive  method   in 140 

Tuberculin    treatment    of 140 


INDEX  259 

.  PAGE 

LYSINS 4 

MARAGLEANO  's  SERUM   7 

MARMOREK  's  ANTI- TUBERCULOSIS  SERUM 7 

METHOD 

Of  determination  of  opsonic  index 4 

Of  making  BE 9 

Of  making  OT 8 

OF  TUBERCULIN   TREATMENT  i 

In  lupus   140 

Minute  dose  51 

Present  day   52 

Eeactive 51 

MILIARY  TUBERCULOSIS,  GENERAL 25 

MISCELLANEOUS    TUBERCULAR   CONDITIONS 132 

MIXED  INFECTIONS   157 

Acute 173 

Acute  af ebrile  177 

Acute  febrile   173 

Chronic 179 

Classification  of 173 

Diagnosis  of  causative  organism  in 158 

In  bone  and  joint  tuberculosis 213 

In  glandular  tuberculosis 210 

In    lung    abscess 231 

In  pulmonary  tuberculosis   (see  RESPIRATORY  MIXED  INFECTIONS) 

In    renal    tuberculosis 101 

Prophylactic  immunization  against 78,  195 

Treatment  of   173 

MORO  TUBERCULIN  TEST 32 

MULTIPLE  MIXED  INFECTION 

Treatment  of  singly  or  combined 181 

NATURE  OF  TUBERCULIN T 

NEEDLES,  HYPODERMIC  47 

NEEDLE  TRACT,  EEACTION  OF  ESCHERICH 32 

NEGATIVE  FINDINGS  IN  CUTANEOUS  TEST 30 

NEGATIVE  PHASE  IN  ACUTE  MIXED  INFECTION 178 

NEPHRITIS 24 

OCULAR  TUBERCULOSIS  137 

OLD  or  ALT  TUBERCULIN 8 

OLIVE  OIL  TREATMENT 

Of  cold  abscess 227 

Of   empyema    233 

Of  lung  abscess 233 

OPEN  GLANDS    71 

OPHTHALMIC  REACTION 35 


260  INDEX 

PAGE 

OPSONIC  INDEX 

Methods  of  determination   of 4 

OPSONINS 3 

ORTHOPEDIC  APPLIANCES   154 

ORTHOPEDIC  TREATMENT   89 

OT    (OLD    TUBERCULIN) 8 

Method  of  making 8 

To  overcome  hypersusceptibility  to 12 

PAIN,  EFFECT  OF  TUBERCULIN  ON 127 

PASSIVE   IMMUNITY    2 

PASTE,  BISMUTH   (see  BISMUTH  PASTE) 

PATHOLOGY,  EFFECT-  OF  TUBERCULIN  ON 130 

PERCUTANEOUS  TUBERCULIN  TEST  OF  MORO 32 

PERITONITIS 133 

Beginning  and  conclusion  treatment  in 137 

Effusion    in 137 

Laparotomy   for    133 

Tuberculin  treatment  of 133 

PERMANENT  DAMAGE  IN  BENAL  TUBERCULOSIS 97 

PERSONAL  HYGIENE 200 

PHAGOCYTES 3 

PHENOMINA  OF  TUBERCULIN  EEACTION 18 

PHYTHISIS   (see  PULMONARY  TUBERCULOSIS) 
PHYSICAL  SIGNS 

Effect   of   tuberculin   on , 129 

In    diagnosis    162 

PHYSIOLOGICAL  ACTION  OF  TUBERCULIN  . . . .- 53 

PLEURISY 

Idiopathic 132 

Tuberculin    treatment    of 132 

POLYVALENT  VACCINES    169 

POSITIVE  FINDINGS  IN  CUTANEOUS  TEST 31 

PRECIPITINS 4 

PREJUDICE  AGAINST  TUREBCULIN,  CAUSES  OF 51,  66 

PREPARATION 

Of  tuberculins   7 

Of  vaccines 164 

PRIMARY 

Mixed  infections  188 

Tubercular   infections    68 

PRINCIPLES  UNDERLYING  PHYSIOLOGICAL  ACTION  OF  TUBERCULIN.  .  53 

PROGNOSIS  IN  PULMONARY  TUBERCULOSIS 123 

PROPHYLACTIC   IMMUNIZATION    78,  195 

Against  acute  exacerbations  of  mixed  infection 197 

Against    epidemic    infections 196 

Against  respiratory  mixed  infection 195 


INDEX  261 

PAGE 

PROPHYLAXIS,   GENERAL,    198 

PULMONARY  ABSCESS  (see  LUNG  ABSCESS) 

PULMONARY  MIXED  INFECTION  (see  RESPIRATORY  MIXED  INFECTION) 

PUL'MONARY  TUBERCULOSIS   105 

Contraindications    to    tuberculin    treatment    in 108 

General  hypersusceptibility  in 112 

Hygienic-dietetic-climatic    treatment    of 107 

Prognosis   and   results   in 123 

Results  of  tuberculin  treatment  in 123 

Statistics  of    105,  126 

Treatment 113 

Beginning 

Of   Acute    122 

Of  Chronic   . 117 

Of    Incipient    114 

Conclusion 

Of   Acute    122 

Of  Chronic   118 

Of    Incipient    ...  114 

Tuberculin  treatment  of,  in  Germany 105 

CLASSIFICATION  OF    110 

Acute  or  active Ill 

Afebrile 112 

Calcareous Ill 

Chronic 110 

Febrile 112 

Fibrous Ill 

Hemorrhagic 11- 

Incipient 110 

PULSE,  EFFECT  OF  TUBERCULIN  ON 128 

PURULENT  EFFUSION 

Prevention   of   reaccumulation 233 

Treatment    of     232 

PYOGENIC  RESPIRATORY  MIXED  INFECTIONS 184 

RADICAL  OPERATION 

As  increasing  general   hypersusceptibility 69,  72 

For   tubercular   adenitis 72,  74 

In   renal   tuberculosis 

RADIOGRAPHY  (see  X-RAY) 

REACTION 

Constitutional    (see   CONSTITUTIONAL   REACTION) 

Effect  of  dosage 55,  56,  59 

Effect   on    intervals 55,  59 

Focal 19,  4°.  17{) 

Local 19. 

Needle  tract,  of  Escherich 32 


262  INDEX 

REACTION — Con.  PAGE 

Of  tuberculin  in  diagnosis 17 

Ophthalmic   or   conjunctiva! 35 

Phenomena  of  tuberculin 18 

Traumatic,    in   cutaneous   test 29 

Tables  showing    _. 59 

READY  MADE  TUBERCULIN  DILUTIONS 16 

RECORDS 

Of  temperature 48 

Of  tuberculin  treatment 43 

RECURRENCE  OF  HYPERSUSCEPTIBILITY 147 

RECURRENT   TUBERCULAR   GLANDS 73,  74,  83 

RENAL  TUBERCULOSIS  ." 95 

Beginning    treatment   in 103 

Conclusion   treatment  in 103 

Difficulty  of  diagnosis 98 

Early    diagnosis    in 98,  99 

Hypersusceptibility  in 101 

Incipient 97 

Mixed  infection  in 101 

Permanent   damage   from 97 

Radical   operation  in 96 

Source  of  infection  of 95 

Tuberculin  in  diagnosis  of 98,  99 

REPORT  OF  TUBERCULIN  TESTS 

Army ! 27 

Binswanger 27 

RESPIRATORY  MIXED  INFECTION 184 

Acute 192 

Catarrhal 184 

Chronic 186 

Classification   of    ; 186 

Primary 188 

Prophylactic   immunization   against 195 

Pyogenic 184 

Secondary 187 

Treatment  of  acute 193 

Treatment    of    chronic 190 

RESPONSE,  IMMUNE    4,  5,  6 

RESULTS  OF  TUBERCULIN  TREATMENT 

In  bone  and  joint  tuberculosis 92 

In  glandular  tuberculosis 74 

In   pulmonary   tuberculosis 123 

On  individual  symptoms 127 

RETENTION  OF  BISMUTH  PASTE 221 

ROENTGENOGRAPHY     (see    X-RAY) 

SEE    (SENSITIZED  BE) 10 


INDEX  265 

PAGE 

SCALES,  OFFICE   47 

SENSITIZED  BE   (SEE) 10 

SERUS  ACCUMULATIONS   88 

SINUSES   (see  FISTULAS) 

SKIN  TUBERCULOSIS   (see  LUPUS) 

SMEAR  FOR  DIAGNOSIS 159 

SOFT  GLANDS  208 

SOURCE  OF  INFECTION,  ELIMINATION  OF 198 

SPECIAL  CONDITIONS  142 

Abscess   formation    144 

Autoinoculation 145 

Constitutional   reaction    142 

Tri-monthly  tests 147 

Tuberculin  intolerance  144 

SPECIAL   TREATMENT    153 

SPUTUM 

During    constitutional    reaction 20 

Tubercle  bacilli  in 20 

STABILITY   OF   DILUTIONS 15 

STANDARDIZATION  OF  VACCINE 164 

STATISTICS 105,  126 

STERIO  X-EAT    224 

STOCK  VACCINES   168 

Polyvalent 169 

SUBCUTANEOUS   TUBERCULIN   TEST 37 

Constitutional  reaction  in 39,  142 

Focal  reaction  in 40 

Local  reaction   in 39 

Safety  of    37 

Serial  method  of  dosage 22,  23 

Symptoms  of   39 

Technique  of    37 

Treatment  of  41 

SUPPURATING  GLANDS  210 

SURGICAL  TREATMENT 

Of  empyema  232 

Of  lung  abscess 232 

Of  tubercular  glands 208 

Eadical,  in  glands 72,  74 

SYMPTOMS 

Of  subcutaneous  tuberculin  test 39 

Eesults  of  tuberculin  treatment  on  individual 127 

SYRINGE 

Bismuth  paste 220 

Tuberculin.  .           14,  46 


264  IHTDEX 

•  PAGE 

TABLES 

Of  dilutions   15 

Of  dosage  in  tests 23,  24 

Of  dosage  in  treatment 57,  59,  60 

Of  dosage  of  BE 60 

Of  dosage  of  OT 57,  59 

Showing  reactions  59 

TBk   (TUBERCULIN  BERANECK) 11 

TECHNIQUE 

Acquiring   of,   for   treatment 65 

Of   bismuth   paste   treatment 220 

Of  subcutaneous  test 37 

Of  tuberculin  administration 54 

Of  Von  Pirquet  test 28 

TEIIPEKATUKE 

As  a  contraindication  to  tuberculin  treatment  in  pulmonary 

tuberculosis 108 

As  a  contraindication  ta  the  tuberculin  test 25 

Curve  in  relation  to  time  of  vaccine  administration 174 

Differentiation    of    142,  177 

Effect  of  tuberculin  treatment  on 128 

Influence  on  treatment 80 

In  pleurisy 133 

Instruction  to  patients  on  proper  taking  of 48 

Eeaction    (see  CONSTITUTIONAL  REACTION) 

Records  of    48 

TOLERANCE 

Acquiring,  by  means  of  OT 12 

Curve 61,  63 

To  toxic  proteins  in  treatment 51,  65 

TOXICITY 

Of  vaccines 173 

TESTS   (see  TUBERCULIN  TESTS) 
THERAPY    (see   TREATMENT) 

TO   (TUBERCULIN  OBERS) 10 

TOA  (TUBERCULIN  OBERS  ALB) 8 

TR    (TUBERCULIN    RESIDUE) 10 

TRAUMATIC  REACTION  29 

TREATMENT 

Acquiring  technique  for   tuberculin 65 

Bismuth  paste   86,  88,  220 

Combined 89,  155,  213,  217 

Effects  of  reactions  on  tuberculin 55,  56,  59 

Intervals  in   (see  INTERVALS) 

Method  of  dosage  in  tuberculin 52,  53,  140 

Of  autoinoculation    147 


INDEX  265 

TREATMENT — Con.  PAGE 
Of  bone  and  joint  tuberculosis  (see  BONE  AND  JOINT  TUBER- 
CULOSIS) 

Of  cold  abscess 227 

Of   constitutional   reaction 41 

Of  deformity   gg 

Of    effusion    231 

Of  empyema  232 

Of  glandular  tuberculosis   (see  GLANDULAR  TUBERCULOSIS) 

Of  lung  abscess 232 

Of  miscellaneous  tubercular  conditions 132 

Of   mixed   infection 173 

Of  mixed  infection  in  bone  cavities  and  fistulas 213 

Of  pulmonary  tuberculosis  (see  PULMONARY  TUBERCULOSIS) 
Of  renal   tuberculosis    (see  EENAL  TUBERCULOSIS) 

Of  respiratory  acute  mixed  infection 193 

Of  respiratory  chronic  mixed   infection 190 

Of  tubercular  glands  (see  GLANDULAR  TUBERCULOSIS) 

Of    tubercular   peritonitis 133 

Of  tubercular  pleurisy 132 

Orthopedic 89 

Principles  involved  in  tuberculin 53 

Proper  record  of 43 

Results  of  tuberculin   (see  RESULTS) 

Special 153 

Surgery  in   (see  SURGICAL  TREATMENT) 
Surgical   (see  SURGICAL  TREATMENT) 

Tuberculin 51 

Vaccine 173 

X-ray  in    224 

TRYPTIC  DIGESTION  AS  CAUSE  OF  SUPPURATION 226 

TUBERCLE  BACILLI 

During    constitutional    reaction 20 

In   sputum    20 

TUBERCULAR 

Coxitis    (see  Fig.   55) 

Filtrates 8 

Glands  (see  GLANDULAR  TUBERCULOSIS) 
Peritonitis   (see  PERITONITIS) 

TUBERCULIN 

AF  (Albumose-Free)    9 

BE  (Bacillary  Emulsion) 9 

Choice  of 12 

Containers 47 

Contraindication  to    21,  108 

Dilutions 13,  14,  47 

Immune  response  to 4,  5,  6 


266  INDEX 

TUBERCULIN — Con.  PAGE 
In  beginning  treatment   (see  BEGINNING  TREATMENT) 
In  conclusion  treatment  (see  CONCLUSION  TREATMENT) 
In  renal  tuberculosis   (see  BENAL  TUBERCULOSIS) 
In  treatment  (see  TREATMENT) 

Intolerance   to 144 

Mixtures  of 11 

Nature  of   7 

Old  or  Alt 8 

OT  or  T 8 

Reaction   in   diagnosis 17 

Results  of,  on  symptoms 127 

SEE    (Sensitized  BE) 10 

Syringe 14,  46 

TBk    (Tuberculin  Beraneck) 11 

TO    (Tuberculin   Obers) 10 

TOA   (Tuberculin  Obers  Alt) 8 

TE    (Tuberculin   Eesidue) 10 

Tuberculol  Landsmann    10 

Tuberculose-Sero-Vakzin .10 

Varieties  of    .     8 

TUBERCULIN  TESTS 

Army    report    of 27 

Binswanger  report  of    27 

Conjunetival 35 

Contraindication  to    21,  24 

Cutaneous 28 

Determination   of    ., 26 

Dosage  in   22 

Escherich's  needle  tract  in 32 

Indications   for    18 

Interpretations  of   19 

Intracutaneous 33 

Percutaneous,  of  Moro 32 

Eepetition  of    21 

Subcutaneous 37 

Treatment  of   41 

Tri-monthly 147 

Von  Pirquet   28 

Variations   in   the   cutaneous 30 

TUBERCULOL  LANDSMANN    10 

TUBERCULOSIS 

General  miliary   25 

Of  bones  and  joints  (see  BONE  ANI>  JOINT  TUBERCULOSIS) 
Of   glands   (see  GLANDULAR  TUBERCULOSIS) 

Of  the  ear 139 

Of  the  eye 137 


INDEX  267 

TUBERCULOSIS — Con.  PAGE 
Of  the  peritoneum    (see  PERITONITIS) 

Of   the   pleura 132 

Of   the   skin '.....  140 

Pulmonary   (see  PULMONARY  TUBERCULOSIS) 
Renal  (see  RENAL  TUBERCULOSIS) 

The   three   stages   of gg 

Vicious   cycle  in g 

UROGENITAL  TUBERCULOSIS  (see  RENAL  TUBERCULOSIS) 

VACCINE 164 

Autogenous 170,  215 

Care  of   168 

Conclusion  of,  treatment 179 

Containers  f  er 166 

Polyvalent 169 

Preparation  of 164 

Standardization 164 

Stock 168 

Time  of,  administration  in  relation  to  temperature  curve. . .  174 

Toxicity    of    173 

Treatment   (see  MIXED  INFECTION) 

Use   of    singly 181 

VACCINE  DOSAGE 

In  acute  afebrile  infection 177 

In  acute  febrile  infection 175 

In  acute  respiratory  mixed  infection 193 

In   chronic  mixed   infection 181 

In  chronic  respiratory  mixed  infection 190 

In  empyema 232 

In  lung  abscess 232 

In  prophylactic  immunization 195 

VARIATIONS  IN  THE  CUTANEOUS  TUBERCULIN  TEST 30 

VARIETIES  OF  TUBERCULINS   (see  TUBERCULIN) 

Vicious  CYCLE  IN  TUBERCULOSIS 6 

VON  PIRQUET  TUBERCULIN  TEST 28 

WEIGHT,  EFFECT  OF  TUBERCULIN  ON 127 

WOLFF-EISNER  's  TEST  35 

X-RAY  FINDINGS 

For    direction    of    bismuth   paste 224 

Showing  effect  of  tuberculin 130 

Sterio.  .                                                                            224 


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